
Class _JR£jlz 



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COPYRIGHT DEPOSIT 



PLATE I. 




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Radiograph of Bronchial Tree (child). Bronchi filled with Shot No. 10. 

Diameter, .038 in. 




DIAGNOSIS 



INCLUDING 



DISEASES OF THE THORACIC AND 
ABDOMINAL ORGANS. 

A Manual for Students and Physicians 



BY 

EGBERT LE FEVRE, M.D. 

PROFESSOR OF CLINICAL MEDICINE AND ASSOCIATE PROFESSOR OF THERA- 
PEUTICS IN THE UNIVERSITY AND BELLEYUE HOSPITAL MEDICAL COLLEGE; 
ATTENDING PHYSICIAN TO BELLEYIE AND ST. LUKE'S HOSPITALS; 
CONSULTING PHYSICIAN TO BETH-ISRAEL HOSPITAL; MEMBER OF 
THE NEYV YORK ACADEMY OF MEDICINE, ETC. 

SECOND EDITION. THOROUGHLY REVISED AND ENLARGED 
Illustrated With 102 Engravings and 16 Plates 




LEA BROTHERS & CO. 
PHILADELPHIA AND NEW YORK 

1905 



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ARY of QONQRESS 
(Two Ocpiss rtectavw.! 

NOV 4 8905 

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Entered according to the Act of Congress in the year 1905, by 

LEA BROTHERS & CO. 
In the Office of the Librarian of Congress. All rights reserved. 



c c 

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TO MY FORMER STUDENTS, 

WHOSE INSISTENT 
•• WHY " 
FURNISHED THE INCENTIVE 

FOR THIS WORK. 



PREFACE TO THE SECOND EDITION. 



In revising this work for its second edition the author 
has preserved its general plan, inasmuch as it represents 
the methods developed in his experience as a teacher. 
Especial emphasis is laid on the altered anatomy of the 
organs under examination, and its relation to the physi- 
cal signs. The respiratory and cardiac sounds, their pro- 
duction and modifications, both normal and pathologi- 
cal, have been discussed more fully than in most books 
of moderate scope, since, unless the student clearly 
understands how these sounds are produced, the tend- 
ency is to regard each variation from normal as path- 
ognomonic of special disease rather than as dependent 
on changes in structure or function which may be pres- 
ent in conditions not necessarily pathological. In this 
way only can diagnostic values be estimated and the 
range and limitations of Physical Diagnosis be under- 
stood. The subject is now taught at an early period in 
the curricula of the medical schools, a circumstance 
which has made it necessary to give a brief account of 
the morbid changes in different organs, and of their 
secondary effects, both immediate and remote. 

This new edition has been thoroughly revised, some 
of the sections have been entirely rewritten, the series 
of illustrations has been enriched, and attention has been 
called to recent modifications in methods of exami- 

(v) 



vi PREFACE. 

nation. The scope of the work has been kept to its title, 
including the subjects of Inspection, Palpation, Percus- 
sion and Auscultation. 

Thanks are due to Dr. Charles B. Slade for the revi- 
sion of the chapter on Topographical and Relational 
Anatomy, and for the preparation of new illustrations 
for that portion of the book ; to Mr. L. B. Goldhorn for 
photographs of the X-Ray outlines of the heart, and to 
Dr. S. D. Curran for assistance in obtaining illustrative 

cases of cardiac disease. 

E. LeP. 

52 West Fifty -sixth street, 

New York City. 



CONTENTS. 

PART I. 
ANATOMICAL. 

CHAPTER I. 
Topographical and Relational Anatomy. . . .17-42 

PART II. 
THE RESPIRATORY SYSTEM. 

CHAPTER 11. 

Inspection 4o-o4 

CHAPTER III. 

Palpation **~ ' y 

CHAPTER IV. 

Percussion i 6-104: 

CHAPTER V. 
Auscultation 105-133 

CHAPTER VI. 
Auscultation (Continued) •• .131-151 

CHAPTER VII. 
Diagnosis of Diseases of Respiratory 

Teact 152-235 

PART III. 
THE CIRCULATORY SYSTEM. 

CHAPTER VIII 

Inspection • - • - 23 < -248 

(vii) 



viii CONTENTS 

CHAPTER IX. 

Palpation 249-2 t 3 

CHAPTER X. 

Percussion 274-284 

CHAPTER XI. 
Auscultation 285-322 

CHAPTER XII. 

Diagnosis of Diseases of the Heart 323-377 

CHAPTER XIII. 

Diagnosis of Diseases of the Pericardium, 378-392 

CHAPTER XIV. 
Diagnosis of Diseases of the Blood-vessels, 393-403 

PAET IV. 
THE ABDOMINAL ORGANS. 

CHAPTER XV. 

Inspection 405-411 

CHAPTER XVI. 
Palpation 412-440 

CHAPTER XVII. 

Percussion 441-451 

CHAPTER XVIII. 

Auscultation 452-454 

. 

part v. 

Examination with X-Ray 455-462 



PHYSICAL DIAGNOSIS. 



PART I. 
ANATOMICAL. 



CHAPTER I. 

TOPOGRAPHICAL AND RELATIONAL ANATOMY. 

Foe convenience in study and reference the entire 
area of the trunk has been divided into surges and 
these surfaces subdivided into regwns ^™TO 
lines and surface prominences The fol owing 18 the 
most uniformly accepted method of demarcation . 

THE CHEST. 

In general terms it may be said Wtto^ 
tow and lateral surfaces of the ^, ar "^S 
those portions of the ehest surf ace which » P ^ 
seen when looking at the chest from in front, 

hehind or from either side. aimnle 

The anterior surface is bounded above by aMge 
curved line connecting the point of junction '^ 

and middle thirds of one e avick w ft he «^ respo^ 
ing point on the opposite side, laterally »yj 
dropped from the ends of fee curved l"*»j£ OTe 
tio, ed, and below by the inferior costal margin. 



2 



JcS 



ANATOMICAL. 



REGIONS OF THE ANTERIOR SURFACE. 

The supraclavicular and the suprasternal regions, 
limited above by the superior boundary of the anterior 
surface, are defined by their names, as are the clavicular 



Fig. 1. 



Supra- 
Sternal 




Regions of the anterior surface of the chest. 

and the sternal regions, the latter being subdivided into 
upper sternal and lower sternal regions by a line drawn 
horizontally through the upper border of the third costal 
cartilage. 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 19 

The infraclavicular region, limited above by the lower 
border of the clavicle, internally by the edge of the 
sternum, and externally by the lateral boundary of the 
anterior surface, is bounded below by a line drawn 
horizontally through the upper border of the third costal 

cartilage. 

The mammary region extends from the lower limit 
of the infraclavicular region to the upper border of the 
sixth rib. (The lower border of the sixth rib is given 
by some writers as its inferior boundary.) Internally 
and laterally it is bounded by continuation downward 
of the lines that form the internal and lateral boundaries 
of the infraclavicular region. 

The inframammarjj region is that portion of the 
anterior surface which lies immediately below the mam- 
mary region. (Fig. 1.) 

The posterior surface is bounded above by a horizon- 
tal line through the spine of the seventh cervical ver- 
tebra, laterally by vertical lines passing through the 
point of insertion of the posterior axillary fold and 
below by the twelfth ribs. 

REGIONS OF THE POSTERIOR SURFACE. 

The scapular region, including the supraspinous and 
infraspinous fossae, is limited above by the superior 
boundary of the posterior surface, below by a horizontal 
line passing through the angle of the scapula, internally 
by a vertical line corresponding approximately with the 
internal border of the scapula and externally by the 
lateral boundary of the posterior surface. 

The interscapular region is that part of the posterior 
surface above the horizontal line through the angle of 
the scapula and between the scapular regions. 

The infrascapular or subscapular region is the re- 
mainder of the posterior surface. 

The right and left interscapular and subscapular 
regions are separated by the vertebral spines. (Fig. 2.) 

The lateral surface is bounded above by the line of 



20 



ANATOMICAL. 



-junction of the nnder-surface of the arm with the 
trunk, anteriorly by the lateral boundary of the anterior 
surface, posteriorly by the lateral boundary of the pos- 
terior surface and below by the inferior costal margin. 



Fig. 2. 




Regions of the posterior surface of the chest. 

REGIONS OF THE LATERAL SURFACE. 

The axillary region is that part of the lateral surface 
which lies above a line drawn from the inferior boun- 
dary of the mammary region to the angle of the scapula. 

The- infra-axillary region is the remainder of the 
lateral surface. 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 21 



LINES. 

The following imaginary vertical lines are used for 
more definite location of various structures: 

The mammillary or nipple line. 

The midclavicular line, identical with the mammillary 
line when the nipple occupies its typical position. 

The parasternal line, midway between the edge oi the 
sternum (sternal line) and the midclavicular line. 

The midaxillary line. 

The midscapular line. 

Table of Contents of the Thoracic Regions.* 



RIGHT SUPRACLA- 
VICULAR. 

The apex of the right 

lung. 
The subclavian vessels. 
The termination of the 
external jugular vein. 
The pleura. 
Lymph nodes. 



RIGHT CLAVICULAR 

The lung. 

The innominate vein. 
The pleura. 
Lymph nodes. 



RIGHT INFRACLA- 
VICULAR. 

The lung. 

The right primary bron- 
chus. 
The superior vena cava. 
The arch of the aorta. 
The pleura. 



SUPRASTERNAL. 



The trachea. 

The (esophagus (very 
deep.) (The aortic 
arch may be displaced 
up into this region by 
pathological changes. 
The common carotid 
artery and internal 
jugular vein lie on the 
bou ndary between 
this and the supracla- 
vicular region). 

The thyroid. 



UPPER STERNAL 

The trachea and pri- 
mary bronchi. 

The ascending and 
transverse arch of the 
aorta. 

The innominate artery. 

The superior vena cava. 

The left innominate 
vein. 

Both lungs. 

The pulmonary artery. 

The pulmonary valve. 

The pleura. 

The appendix of the 
right auricle. 

The apex of the peri- 
cardium. 

(The right innominate 
vein is on the bound- 
ary between this and 
the right infraclavic- 
ular region.) 

The thymus. 

Lymph nodes. 



LEFT SUPRACLA- 
VICULAR. 

The apex of the left 

lung. 
The subclavian vessels. 
The termination of the 

external jugular vein. 
The pleura. 
Lymph nodes. 



LEFT CLAVICULAR. 

The lung. 

The innominate vein. 

The common carotid 

artery. 
The subclavian artery. 
The pleura. 
Lymph nodes. 



LEFT INFRACLA- 
VICULAR. 

The lung. 

The primary bronchus. 
The left auricle. 
The pleura. 



22 



ANATOMICAL. 



RIGHT MAMMIL- 
LARY. 

The lung. 

The right auricle. 

The diaphragm. 

The right bronchus and 

its branches. 
The liver. 
The pleura. 



LOWER STERNAL. 



Both lungs. 

The pericardium. 

The base of the right 

ventricle. 
The base of the left 

ventricle. 
The left auricle (deep). 
The right auricle. 
The mitral, aortic and 

tricuspid valves. 
The inferior vena cava. 
The pleura. 



LEFT MAMMIL- 
LARY. 

The lung. 

The right and left ven- 
tricles. 

The left bronchus and 
its branches. 

The diaphragm. 

The liver. 

The stomach. 

The pleura. 



RIGHT INFRA. MAMMARY. 

The lung. 
The diaphragm. 
The liver. 
The pleura. 



LEFT INFRAMAMMARY. 

The lung. 
The diaphragm. 
The liver. 
The stomach. 
The pleura. 



RIGHT AXILLARY. 

The lung. 
The pleura. 
Lymph nodes. 



LEFT AXILLARY. 

The lung. 
The pleura. 
Lymph nodes. 



RIGHT INFRA-AXILLARY. 

The lung 
The diaphragm. 
The liver. 
The pleura. 



LEFT INFRA- AXILLARY. 

The lung. 

The diaphragm. 

The spleen. 

The stomach (this gives 
a tympanitic quality to the 
percussion sound in this re- 
gion; if it contains gas). 

The pleura. 



RIGHT SCAPULAR. 

The lung. 
The pleura. 



INTERSCAPULAR. 

The lungs. 

The trachea and bronchi 

The aorta. 

The oesophagus. 

The thoracic duct. 

The vena azygous major. 



LEFT SCAPULAR. 

The lung. 
The pleura. 



RIGHT. 

The lung. 
The diaphragm. 
The liver. 
The kidney. 
The pleura. 



INFRASCAPULAR. 

MEDIAN. 

The aorta. 
The oesophagus. 
The thoracic duct. 
The vena azygous major 
The diaphragm. 



LEFT. 

The lung. 
The diaphragm. 
The spleen. 
The kidney. 
The pleura. 



* Organs are mentioned in every region that usually contains any part 
of them. 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 23 



THE TRACHEA AND BRONCHI. 

The trachea passes almost vertically down through 
the middle of the suprasternal region, deflected slightly 
to the right in the upper sternal region by the arch of 
the aorta, where it is found dividing into right and 
left primary bronchi opposite the junction of the first 
and second pieces of the sternum. (Fig. 3.) This level 
is indicated on the surface by a palpable transverse 
ridge on the sternum opposite the second costal cartilage. 

Fig. 3. 




Diagram showing the relation of the trachea and bronchi to the 

anterior chest wall. 

From here the right bronchus continues downward and 
to the right, conforming very nearly to the direction of 
the trachea just above it, passes behind the extreme 
inner end of the second intercostal space and the junc- 
tion of the third costal cartilage with the sternum. 
Behind the upper border of the third costal cartilage 
it gives off its first branch, which passes outward and 
upward to the upper lobe toward the right apex. 



24 



ANATOMICAL. 



The right primary bronchus is slightly larger in 
calibre than the left, and its first or hyparterial branch 
is given off only half an inch from the" tracheal bifurca- 
tion and before the bronchus is surrounded by lung 
tissue. The bronchus continues downward and outward 
into the lung substance, to break up into its various 
branches deep in the mammary region. Posterior] v the 



Fig 




Diagram showing the relation of the trachea and bronchi to the 

posterior chest wall. 

tracheal bifurcation is opposite the disk between the 
fourth and fifth dorsal vertebra, or the spinous process 
of the fourth dorsal vertebra. The right bronchus and 
its branches, being within the right interscapular region, 
influences the auscultatory sound in the fourth inter- 
costal space posteriorly. 

The right primary bronchus is in relation behind 



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TOPOGRAPHICAL AXD RELATIONAL ANATOMY. 25 

with the right pneumogastric nerve and 'one or more 
lymphatic glands. The oesophagus, vena azygons major 
and bronchial artery also lie jnst posterior to it, but 
separated from it by the nerve and glands jnst named. 

Fig. 5. 




Bronchi (child) filled with shot. No. 10. Diameter, .03S inch. 

Lateral view. 

Above it is the vena azygons major, arching forward to 
join the superior vena cava, and in front of the bronchus 
is the right pulmonary artery, with the superior vena 
cava and the right phrenic nerve. (Fig. 7.) 

The left primary bronchus is given off at the bifnrca- 



26 



ANATOMICAL. 



tion of the trachea (Fig. 3). It immediately passes 
under the arch of the aorta and goes obliquely down- 
wards and to the left in a direction almost at a right 
angle to that of the right bronchus, thus being at great 



Fig. 6. 




Bronchi (adult) filled with shot, No. 4. Diameter, .110 inch. 



variance to the direction of the trachea. It passes 
behind the junction of the third costal cartilage with the 
sternum, its first branches being given off in the left 
mammary region twice as far from the tracheal bifurca- 
tion as the first branch of the right bronchus, and after 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 27 

the bronchus is well surrounded by lung substance. The 
calibre of the left bronchus is slightly less than that of 
the right bronchus. In the back it lies in the left inter- 
scapular region a little lower than the right bronchus 

(Fig. 4). 

The left bronchus is in relation posteriorly with the 
left pneumogastric nerve and one or more lymph glands, 
the oesophagus being farther back. Still more posteriorly 
and to the left of the median line is the descending 
aorta. The thoracic duct lies against the anterior sur- 
faces of the bodies of the vertebra in this region, cross- 
ing obliquely from right to left and upwards. The pul- 
monary artery lies first in front and then passes upwards 
and to the left above the bronchus, the left auricle being 
placed close below and anterior to it. (Fig. 12 and 
Fig. 7.) 

The difference in size, direction and arrangement of 
the two bronchi have an important influence on the nor- 
mal variance of certain physical signs found in corre- 
sponding regions on the two sides. The relations above 
mentioned will explain many of the complex physical 
findings and symptom groups to be met with in certain 
pathological alterations in these structures. 

THE LUNGS. 

The lungs occupy all of the thoracic cavity except the 
mediastinum, and their apices extend above the first 
ribs from one-half to one and one-half inches, rising 
with inspiration and receding with expiration. The 
right lung is larger than the left in the ratio of about 
11 to 10. It is wider and shorter than the left, to give 
place for the liver on the right and the heart on the left 
side. The lower border of the lungs at the end of 
expiration is on a level with the sixth rib in the mam- 
millary line, the eighth rib in the midaxillary line and 
the apex of the spinous process of the tenth dorsal ver- 
tebra posteriorly. The anterior borders of both lungs 
reach the median line above about the middle of the 



28 ANATOMICAL. 

first piece of the sternum and pass down in the median 
line in apposition with each other to a point opposite the 
junction of the fourth costal cartilage with the sternum, 
where the anterior border of the left lung turns obliquely 
off to the left and downwards parallel with and behind 
the lower border of the fourth costal cartilage. About 
three inches from the median line it goes nearly ver- 
tically down to a point just behind the upper border of 
the fifth costal cartilage, about three and one-half inches 
left of the median line, then turns inwards and down- 
wards to the upper border of the sixth costal cartilage, 
where it joins the inferior border, thus leaving a small 
area of the pericardium and the heart uncovered by the 
lung. The anterior border of the right lung continues 
vertically down in the median line to the lower end of 
the sternum, where it joins the inferior border. Pos- 
teriorly the lungs extend close up against the vertebral 
column on both sides. 

The main fissure of the lung, which lies above the 
lower lobe on either side, reaches the surface of the lung 
posteriorly opposite the interval between the apices of 
the spinous processes of the second and third dorsal 
vertebrae, and passes more or less obliquely downwards 
and forwards to join the inferior border of the lung a 
short distance from the sternum, a little further outward 
on the right than on the left side. On the right side 
the short fissure (usually present) which lies above the 
middle lobe appears on the anterior surface of the lung 
in its anterior border on a level with the fourth costal 
cartilage and passes almost horizontally outwards to the 
main fissure. It will be seen that the extreme apex of 
the lower lobe lies in the third intercostal space close 
to the vertebral column on either side. The highest or 
central portion of the diaphragmatic or inferior surface 
of the right lung at the end of expiration is on a level 
with the fourth intercostal space, while that of the left 
lung is level with the lower border of the fifth rib. These 
surfaces are in contact with the superior surface of the 
diaphragm, which reaches to the elevations stated. 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 



29 



The close proximity of the under-surf ace of the right 
lung to the liver, which lies against the under-surf ace of 
the diaphragm, is of special importance in connection 
with abscess of the liver, a condition which not uncom- 
monly gives rise to secondary involvement of the right 
lung or pleura, and sometimes physical signs which 
may be confusing, unless the relations just mentioned 
are kept in mind. 

Fig. 7. 



Left Pleural Sac 



Left Phrenic Ncr»c 
Left Pulmonary Artery 

Left Bronchus 

Lymph Glands 

Left Vagus 

Descending Aorta 



> Left Eleurdl Sac 




Right Pleural Sac 



Ascending Aorta 
Sight Phrenic .Verve 
Suj>criur Vena Cava 
-Right Pulmonary Artery 

Right Bronchus 
Lymph Glands 
i> Right Vagus 
Bronchial Artery 
(Jctstqihayus 
Vena Aiygus Major 



Right Pleural Sac 



Mediastinum 



Thoracic Duct 



Diagram showing the anteroposterior relation of the important 
structures in the thorax on a level with the lung roots. The heart is 
placed below and anterior to this region. 

THE PLEURA. 

The pleural sac covers the lung at all points. On the 
left side it comes forward, covering most of that part 
of the pericardium which is not covered by the lung, 
reaching very near to the left edge of the sternum Its 
lower limit reaches further down than the inferior 
border of the lung. This complemental space begins id 
front near the median line, increasing gradually from 



30 



ANAT03IICAL. 



before backward to the lateral surface of the chest, 
where it is of greatest depth, diminishing more grad- 
ually as it passes on the posterior surface of the chest, 
the pleura reaching clown to the body of the twelfth 
dorsal vertebra in the median line posteriorly one and 
one-half vertebral bodies lower than the lung at the 

Fig. 8. 




Relation of lungs, pleura, heart and liver to bony thorax. 



end of expiration. Most of the complement al space is 
occupied by the lung in extreme inspiration. 

The mediastinum is that part of the thoracic cavity 
which lies between the two pleural sacs. It contains all 
of the intrathoracic structures except the lungs and 
pleura. (Fig. 7.) 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 31 



THE PERICARDIUM. 

The pericardial sac, attached by its broad base to the 
diaphragm, is invaginated by the heart, and its apex, 
which is directed' upwards, extends by diverticula- 
upon the great vessels about two inches from their 

Fig. 9. 




Relation of lungs, pleura, spleen and kidneys to bony thorax. 

origin. Its most important relations to the lung and 
pleura, with which it is in contact through most of its 
extent, have been mentioned. Its relation to the anterior 
thoracic wall is practically the same as that of the heart, 
with some additional extension upwards, where it is 
reflected upon the great blood-vessels. 

The serous surfaces of the pericardium and of the 
pleura are bathed in sufficient fluid to render their 
motions normally noiseless and free from friction. 



32 



ANATOMICAL. 



THE HEART. 

Besides a knowledge of the shape, arrangement and 
structure of the several cavities and valves of the heart, 
as well as the general position of the organ, the following 
points are of special significance in diagnosis : 

Fig. 10. 
A nterior 



Left 




■Right 



Posterior 



Diagram showing the horizontal relations of the orifices at the base 

of the heart. 



The right ventricle forms the greater part of the 
anterior aspect of the heart and also its inferior border. 

The right auricle forms most of its visible base from 
this position (the front), while the left ventricle can be 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 33 

seen to a very slight extent all along the extreme left 
border, forming the true apex. The small appendix of 
the left auricle appears above, just to the left of the 
origin of the pulmonary artery, thus completing the 
anterior aspect of the heart. The left ventricle and left 
auricle are chiefly posterior. 

The pulmonic orifice lies in front of the aortic orifice, 
its center being a little to the left of the center of the 
a«»rtic orifice. "The tricuspid orifice is behind and to the 
right of the aortic orifice, so that the aortic orifice is 
directly between the tricuspid and pulmonic. The 
mitral orifice is placed behind and to the left of the 

aortic. (Fig. 10.) 

These four valves are each on a different plane from 
above downward in the following order: Pulmonic, 
aortic, mitral and tricuspid, the interval between the 
planes of the aortic and mitral orifices being greater 
than the other two intervals. The plane of the surface 
of the pulmonic valve faces upward ; that of the aortic 
orifice, upward to the right and slightly forward; that 
of the mitral, upward to the right and slightly backward, 
while that of the tricuspid is directed to the right and 
slightly upward. The first two are given in the direction 
of the normal blood current and the last two in the direc- 
tion of a regurgitating current. 

The under-surface of the heart rests on the dia- 
phragm, which separates it from the cardiac end of the 
stomach and left lobe of the liver. The left ventricle 
and auricle and the left margin of the right ventricle are 
covered by lung and pleura, the lung here being quite 

thin. 

The projection of the outline of the heart upon the 
anterior surface of the chest is approximately as fol- 
lows : 

A point in the fifth intercostal space three and one- 
half inches to the left of the median line indicates the 
site of the apex. Connect this with a point on the lower 
border of the left second costal cartilage one inch to the 



34 



ANATOMICAL. 



left of its sternal end by a line gently curved, with its 
convexity to the left; then connect this last point with a 
point on the upper border of the right third costal car- 
tilage one-half inch from its sternal end by a straight 



Fig. 11. 




Pulmonic 
Aortic 
Mitral 
Tricuspid 



Apex 



Diagram showing the approximate outline of the heart and the 
relative location of the orifices. 

line, and connect this point and the apex with the right 
seventh costo-sternal articulation by straight lines. 

The pulmonic orifice is directly behind the upper part 
of the third left costo-sternal articulation. 

The aortic orifice is behind the sternum opposite the 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 35 



lower part of the third left costo-sternal articulation to 
the left of the median line. 

The mitral orifice is behind the sternum opposite the 
fourth costo-sternal articulation, slightly to the left of 
the median line. 

The tricuspid orifice is behind the sternum opposite 
the fourth intercostal space and in the median line. 
(Fig. 11.) 

THE AORTA. 

The aorta, arising at the aortic orifice, first appears 
between the pulmonary artery and the apex of the right 
auricle,, coming forward and upward. It soon attains a 

Fig. 12. 




Diagram showing relations between great vessels at base of heart and 

bronchi. 



position anterior to the pulmonary artery, which 
upwards and then backward, dividing into the righ 
left pulmonary arteries, the right going behind the 
ascending aorta, which continues upwards to the right 



goes 
ght and 



— 



36 



ANATOMICAL. 



and forward, approaching very close to the posterior 
surface of the sternum behind its right border at the 
second intercostal space, where it "usually projects 



Fig. 13. 




Regions of the abdomen. 



slightly into the right infraclavicular region. From 
this point it arches backwards to the left of the trachea 
and over the left primary bronchus, with which struc- 



PLATE III. 



» 













Situation of the Viscera (Anterior Aspects 

Outlines of heart and vessels — broad red lines Margins of 
lungs and individual lobes— dotted green lines. Limits of 
pleural saes solid green lines. Liver — red shading. Stomach 
— green shading. 

(In part after His-Spalteholz and Lusehka.l 



PLATE IV 



U—W-^T^J 




Situation of the Viscera (Posterior Aspect). 

Outlines of heart and vessels — broad red lines Margins of 
lungs and individual lobes— dotted green lines. Limits of 
pleural saes-solid green lines. Liver— red shading. Stomach 
—green shading. 

(In part after H is-Spalteholz and Lusehka.l 



PLATE V. 







Situation of the Viscera (Right Lateral Aspect). 

Margins of lungs and of individual lobes— dotted 
green lines. Limits of pleural saes — solid green lines. 
Liver and spleen— solid red lines. Diaphragm — dotted 
red lines Stomach (portion not covered by lung") — 
green shading. 

(In part after Lusehka.) 



PLATE VI 




Situation of the Viscera (Left Lateral Aspect). 

Margins of lu.ngs and of individual lobes— dotted 
green lines. Limits of pleural saes solid green lines. 
Liver and spleen — solid red lines. Diaphragm — dotted 
red lines. Stomach (portion not covered by lung) — 
green shading. 

(Tn part after Lusehka.) 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 37 

tures it is in direct contact. (This relation has an 
important bearing upon the causation of tracheal tug- 
ging, which occurs in aneurism of the aortic arch. (Fig. 
12.) Going backwards and downward to the left of the 
oesophagus the descending aorta reaches the left side 
of the vertebral column at the lower border of the fourth 
dorsal vertebra. It then goes down on the surface of the 
vertebral column, gradually approaching the median 
line, where it is located as it goes between the crura of 
the diaphragm, becoming the abdominal aorta at the 
lower border of the twelfth dorsal vertebra. 

THE ABDOMEN. 

Regions: Draw two horizontal lines across the sur- 
face of the abdomen, one through the lower border of the 
tenth costal cartilage (i. e., the subcostal line), the other 
through the highest points of the iliac crests (or through 
the tubercles felt on the outer lip of the crest of the 
ilium about two inches posterior to the anterior superior 
spine, i. e., the intertubercular line). Then erect two 
vertical lines on either side, from the center of Pou- 
part's ligament (i. e., the right and left Poupart lines), 
and the abdominal surface is thus divided into nine 
regions, namely : in the middle, from above downwards, 
epigastric, umbilical and hypogastric or suprapubic; on 
either side, hypochondriac, lumbar, and iliac or in- 
guinal. (Fig. 13.) (Plates III., IV., V. and VI.) 



38 



ANATOMICAL. 



Table of Contents of the Abdominal Regions * 



RIGHT HYPOCHON- 
DRIAC. 

The liver. 

The gall-bladder. 

The hepatic flexure of 

the colon. 
The right kidney. 



EPIGASTRIC. 

The stomach. 

The liver. 

The transverse colon. 

The omentum. 

The pancreas. 

The duodenum 

Both kidneys and supra- 
renal capsules. 

The coeliae axis. 

The aorta. 

The posterior extremity 
of the spleen. 

Lymph nodes. 



RIGHT LUMBAR. 

The ascending colon. 
The right kidney. 
The small intestine. 



LEFT HYPOCHON- 
DRIAC. 

The spleen. 

The stomach. 

The pancreas. 

The spleenic flexure of 

the colon. 
The left kidney. 
The left extremity of 

the liver. 



UMBILICAL. 

The transverse colon. 
The omentum. 
The duodenum. 
The small intestine. 
Right kidney (left kid- 
ney occasionally). 
The aorta. 
Lymph nodes. 



LEFT UMBILICAL. 

The descending colon. 
The omentum. 
The left kidney (occa- 
sionally). 
The small intestine. 



RIGHT INGUINAL 
(OR ILIAC) 

The Caecum (the origin 
of the appendix is 
behind the right Pou- 
partline). 



HYPOGASTRIC. 

The small intestine. 

The sigmoid flexure 
(the bladder in chil- 
dren or if greatly dis- 
tended, and the uterus 
in pregnancy;. 

The caecum. 

Lymph nodes. 



LEFT INGUINAL 
(OR ILIAC.) 

The sigmoid flexure. 



* Organs are mentioned in every region that usually contains any part 



of them 



THE STOMACH. 



The general shape of the stomach is characteristic. 
The cardiac or oesophageal orifice is immediately behind 
the seventh costo-sternal articulation on the left side. 
The fundus is in contact with the under-surface of the 
diaphragm. The great curvature or superior, left and 
inferior border or margin follows a well-pronounced 
curve with its convexity to the left, and is in contact with 
the diaphragm, except in its lower portion it comes from 
under the left inferior costal margin one and one-quarter 
inches above the subcostal line, from which point it goes 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 39 

almost horizontally to the right and passes behind the 
free border of the liver just to the right of the median 
line. The pylorus is just to the right of the median line 
one and one-quarter inches above the subcostal line and 
behind the left lobe of the liver. It is carried to the 
right behind the quadrate lobe when the stomach is dis- 
tended. 

The stomach lies in front of the abdominal aorta, the 
pancreas and the left kidney. Its great curvature is in 
relation with the spleen, to the left, and the transverse 
colon and its meso-colon lie immediately below it. The 
lesser curvature, slightly concave to the right, lies to tin- 
left of the median line. The cardiac orifice, part of 
the fundus, the lesser curvature and the pylorus are cov- 
ered anteriorly by the free border of the liver. The long 
axis of the stomach is about parallel with the inferior 
border of the liver. 

It will be seen that the stomach is in contact with the 
anterior abdominal wall to a comparatively small extent 
in the epigastric region, and to a very slight extent in the 
left hypochondriac region. 

THE LIVER. 

The liver completely fills the right and middle of the 
dome of the diaphragm, its left lobe extending in con- 
tact with the under-surface of the diaphragm in front 
of the stomach and oesophagus as far as one-third of an 
inch to the left of the left Poupart line. Its lower 
border corresponds approximately with a line drawn 
from a point immediately below the lower extremity of 
the right costal margin to a point one inch below the left 
nipple. Then connect these points with a point one-half 
of an inch below the right nipple by lines slightly con- 
cave toward the liver, and the organ is more or less accu- 
rately outlined. Posteriorly and to the right its limits 
are about those of the diaphragm. 

The gall bladder presents its fundus (usually in con- 



40 ANATOMICAL. 

tact with the anterior abdominal wall) immediately 
beneath the point where the right Poupart line crosses 
the inferior costal margin (i. e., in the angle formed by 
the outer border of the right rectus muscle and the free 
border of the ribs). 

THE SPLEEN. 

The spleen is placed well back in the left hypochon- 
driac region against the diaphragm, with the splenic 
flexure of the colon in front of and below it, the stomach 
against it internally and the upper part of the left kid- 
ney posteriorly and internally. It lies between the 
ninth and twelfth ribs — its long axis is nearly parallel 
with the posterior portion of the tenth rib. Its posterior 
extremity is about one and three-quarter inches from the 
vertebral column. It is usually about Rve inches long 
and three inches wide. It glides up and down with 
respiration, but cannot be palpated when normal. 

THE KIDNEYS. 

The kidneys are retroperitoneal and rest upon the 
psoas and quadratus lumbarum muscles and partially 
against the diaphragm and transversalis abdominis. 
The suprarenal capsules cap them above, tilting slightly 
inwards. The left kidney, usually on a higher plane 
than the right kidney, reaches as high as the eleventh rib 
behind and, as a rule, lies entirely above the subcostal 
line, _ Its inferior end just reaches to or very little below 
this line, while the right kidney usually projects slightly 
into the umbilical region, the epigastric region contain- 
ing the greater part of both kidneys. 

THE PANCREAS. 

The pancreas is retroperitoneal. Its head, which lies 
on a level with the body of the second and upper part of 
the third lumbar vertebra just to the right of the median 
line, is embraced by the duodenum superiorly to the 



TOPOGRAPHICAL AND RELATIONAL ANATOMY. 41 

right and inferiorly. All the organ except the tail and 
very little of the body lies in the epigastric region, with 
the aorta, the vena cava and the left kidney behind it. 
The tail just touches the spleen in the hypochondriac 
region. The stomach lies in front of the body and fail, 
and the superior mesenteric artery and vein pass for- 
ward from below the pancreas in the median line 
between it and the duodenum. 

THE DUODENUM. 

The duodenum is imperfectly horseshoe shaped, has 
no mesentery and is thus fixed in its position against the 
posterior abdominal wall and the right kidney. The 
pyloric end is in the epigastric region opposite the first 
Lumbar vertebra behind the free border of the liver, just 
to the right of the median line. It ends in the jejunum 
at the left side of the second lumbar vertebra, also in the 
epigastric region, about one inch above the subcostal line. 
The lowest part of the intermediate portion of the duo- 
denum lies in the upper part of the umbilical region. 

THE C.ECUM AND APPENDIX. 

The caecum is two and one-half inches long and rests 
upon the right psoas muscle near the pelvic brim, with 
its upper end directed upward and to the right, to be 
continued into the ascending colon. It lies chiefly in 
the right iliac region, and is usually entirely covered by 
peritoneum. The ileo-caecal valve is on its inner and 
posterior aspect at its upper end. The ileo-ca^cal valve 
usually lies immediately behind the intersection of the 
intertubercular and right Poupart lines. 

The vermiform appendix comes off from the inner 
and posterior aspect of the ca?cum about one and one- 
quarter inches below the ileo-csecal valve. The last 
point, the point of origin of the vermiform appendix, 
corresponds on the anterior surface of the abdomen to a 
point on the right Poupart line about one and one-quar- 






42 ANATOMICAL. 

ter inches below the intertubercular line. From this 
point the appendix usually runs in one of the following 
three directions into the true pelvis, upward behind the 
cscum or upwards and inwards towards the spleen. Its 
length varies greatly, the average being three and one- 
half inches, while its diameter, also variable, is usually 
about one-quarter of an inch. 

THE ABDOMINAL AORTA. 

The abdominal aorta begins in front of the lower 
border of the twelfth dorsal vertebra, passes down to the 
left side of the lower border of the fourth lumbar ver- 
tebra, where it bifurcates a little below and to the left 
of the center of the umbilical region into right and left 
common iliac arteries. 

Directly behind it is the vertebral column and to its 
right is the inferior vena cava, the left renal vein cross- 
ing in front of it. The cceliac axis is given off immedi- 
ately below the aortic opening in the diaphragm, about 
the center of the epigastric region. 



PART II. 
THE RESPIRATORY SYSTEM. 



CHAPTER II. 

INSPECTION. 

By inspection is understood the act of viewing the 
patient, so as to learn all that may be observed by the 
sense of sight. Inspection is one of the most important 
methods of physical diagnosis, and all systematic exami- 
nations should begin with it; and while it is not final, it 
is valuable in determining certain essential facts that are 
further differentiated by the other methods of physical 
diagnosis. 

The technique of inspection is as follows : 

(1) The patient should have the thorax as exposed 
as is possible. In children and in the male adult all 
clothing should be removed from the chest except that 
which may be necessary to avoid chilling of the surface. 
In the female, delicacy may demand that the patient be 
thinly covered, but wherever it is required the examiner 
should not hesitate to demand that the surface be bare, if 
only a part at a time, so that correct observations may 
be made. Where for any reason it is impossible to bare 
the chest thoroughly, much of the observation that would 
ordinarily be made by inspection must be made by pal- 
pation. 

(2) Inspection may be made with the patient either 
standing, sitting or in the recumbent posture, according 
to the circumstances of the case. 



44 THE RESPIRATORY SYSTEM. 

When the patient is able, the standing or sitting 
posture is preferable, inasmuch as it is easier for the 
observer, and the movements of the chest are not inter- 
fered with. The patient should assume a natural or 
customary posture. Usually as soon as inspection is 
commenced they try to assume a "correct" posture. 

(3) It is necessary that the light fall equally on both 
sides, as the value of inspection is in the comparison of 
one portion of the chest with the corresponding portion 
of the opposite side. The observer generally stands 
directly opposite the patient, so as to have both sides 
within the range of vision. Where it is necessary to 
determine slight variations in the upper portion of the 
thorax, it can often be best done by the observer stand- 
ing behind the patient and looking over the shoulder 
and downward along the clavicle and upper ribs. This 
Avill show the slightest degree of depression in these 
areas. 

NORMAL CHEST. 

The size of the normal chest varies within wide 
limits, and also with the age and sex of the individual. 
In determining whether or not its variations are within 
the normal limits, it is necessary to consider the general 
physique of the patient, as the size of the thorax should 
bear a definite relation to height and weight. 

It is extremely difficult to describe a perfectly normal 
chest. The thorax should be well developed, although 
it is only one in four persons that have perfectly and 
symmetrically developed chests. The neck should bear 
certain definite relations to the bony thorax, and, 
according to the general physique of the patient, the 
neck will be long or short and its relations will vary 
according to the development of the upper portions of 
the body. 

The direction of the clavicles varies with the indi- 
vidual. In the broad, square-shouldered individual they 
lie almost in a horizontal plane, while in those with 



INSPECTION. 45 

sloping shoulders the outer border tends to slope down- 
wards and backwards to meet the tip of the 'shoulder 
blade. Above the clavicle there is, normally, a slight 
depression, called the supraclavicular depression or 
fossa. The depth of this depression varies in individual 
cases, and whether or not it is normal can only be judged 
by comparing it with the general contour of the chest. 
A certain form of clavicle will give the appearance of 
deep supra- and infra-clavicular fossae. The same effect 
may occur on one side from deformity of the spine. 
Increase in the depth of the depression above the clavicle 
occurs in those conditions which cause diminution of 
the size of the apex of the lung, interfering with its 
normal distension when the thorax is enlarged in respira- 
tion. These conditions may affect the entire lung, caus- 
ing general contraction of the chest, as in general pul- 
monary fibrosis, etc., or may affect only the apex of one 
or both lungs. While a number of diseases may cause 
this local condition, the most important is pulmonary 
tuberculosis. 

The sternum normally is carried forward and down- 
ward from its junction with the clavicle. At the junc- 
tion of the upper and middle portion of the body of the 
sternum the so-called angle of Ludwig is formed. This 
varies in individual cases, and is increased in certain 
diseases of the respiratory tract. 

The ribs curve forward and meet the sternum so as to 
give a gradually increasing depth to the chest from 
above downwards. There is also a gradual increase in 
the angle with which they join the sternum from above 
downwards. At the epigastric notch the angle is well 
marked, and its acuteness varies with the general con- 
tour of the chest. 

The intercostal spaces are of a definite width, accord- 
ing to the shape of the thorax. They should be slightly 
depressed, and in a well-developed thorax are visible} 
only in the lower portions. 

Posteriorly, the scapula lies flat upon the ribs, and 



46 TEE RESPIRATORY SYSTEM. 

the spine is, normally, slightly curved toward the right 
side. 

The physiological departures from the perfect chest 
have been variously described as long and short, broad 
and narrow, deep and hollow. All these variations, 
though quite consistent with health, may give: the student 
great difficulty in determining whether or not they are 
within the range of normal. 

As the development of the chest varies greatly in dif- 
ferent individuals, many chests are seemingly indicative 
of some intrathoracic diseases which depend upon non- 
development of the bony thorax and of the lungs during 
the maturing period of life. 

How can it be determined if the shape, form and size 
of the chest are within the range of normal for the indi- 
vidual under observation ? 

This can be done only by taking into consideration 
not only the thorax, but the entire bony skeleton as well., 
and determining if the thorax harmonizes with it. The* 
social status of the individual, the general physique, 
occupation, etc., must be fully considered. Faulty habits 
of posture may cause slight asymmetry of the bony 
thorax without in any way influencing the function of 
the contained organs. The observer must not form thf« 
inference that each departure from the ideal thorax is 
pathological, but must note the variations from the 
normal, and by the other methods of physical diagnosis 
determine if there is any change in the location, struc- 
ture or function of the underlying thoracic organs. 

Deviations from the normal chest have been classified 
as follows : 

PATHOLOGICAL CHESTS. 

(1) The Barrel-shaped, or Emphysematous Chest.- — In 

this form there is an increase in all of the diameters of 
the chest, especially marked in the antero-posterior. 
The chest assumes a type more nearly approaching that 
seen in the infant. (Fig. 14.) The position is one of 



INSPECTION. 



47 



full, forcible inspiration. The clavicle and sternum 
are carried upward and forward by the action of the 
auxiliary muscles of inspiration ; the neck is shortened ; 
the infraclavicular spaces may be deeper than norma], 
shallower, or may be even projecting. The scapulae are 
thrown upwards, outwards and forwards, and project 



Fig. 14. 




Bilateral enlargement of emphysema. 
Outer line = a circle drawn to show how nearly the emphysematous 

approaches the circular shape. 
Dotted line = natural adult chest. 
Inner line = emphysematous chest. 

Actual measurement in centimetres 
Circumference = natural, 89.0 emphysematous, 87.75 
Transverse = " 29.6 " 27.25 

Anteroposterior = " 22.25 " 25.4 (Dr. Gee.) 

from the rounded thorax. The normal anteroposterior 
curvature of the spine is increased. 

Bilateral or uniform enlargement is most frequently 
caused by pulmonary emphysema (large lung) : it occurs 
also during attacks of asthma (temporary emphysema), 
bilateral pleurisy with effusion, hydro-thorax and cancer 
(rare). 



48 



THE RESPIRATORY SYSTEM. 



(2) The Paralytic, Alar, or Pterygoid Chest. — In this 
type there is an abnormal flattening of the sternum 
and ribs, so that the anteroposterior diameter of the 
chest is diminished and there is a slight increase in the 
lateral diameter. (Fig. 15.) 

The depression of the ribs and of the sternum carries 
the sternal end of the clavicle downwards, lengthening 
the neck and causing the chin to project farther forward 
than normal over the anterior plane of the thorax, giving 
a characteristic appearance to the individual. 

Fig. 15. 



R f 




/5 c 



The flat or phthisical chest, short anteroposterior, long traverse 

diameter. (Gee.) 

The angle of the plane of the clavicle with the scapula* 
and sternum alters the depressions above the clavicles, 
increasing their depth, the intercostal spaces are deep- 
ened. The shoulder blades are depressed and stand out 
from the ribs, giving the winged appearance (alar, or 
pterygoid). 

The movements on quiet breathing may be nearly 
normal in frequency and extent, but on exertion or 
forced breathing expansion is less than normal, and 
the movements become more rapid. 

This type may be simulated in marked emaciation by 
diminution in the soft parts which normally give the 



INSPECTION. 49 

rounded contour to the upper portion of the chest. Lack 
of muscular development, or changes in the muscles of 
respiration, such as occur from long recumbence in bed, 
cause slight depressions of the bony thorax, due to feeble 
inspiratory efforts. Symmetrical depressions of the 
thorax in the above conditions are easily differentiated 
from those dependent upon pathological intrathoracic 
conditions by noting that the normal contour of the bony 

Fig. 16. 




Transverse section of a rachitic chest at level of sixth thoracic vertebrae. 

Circumference, 32% inches; right half, 16% inches; 

expansion, 2 inches. 

thorax is preserved, although there may be a slight 
flattening of the chest. 

This type of chest has also been called the 
Phthisical. In many cases of pulmonary tuberculosis 
the flattening of the thorax is more apparent than real, 
being due to the marked emaciation and loss of muscle- 
tissue. Actual measurements in cases of pulmonary 
tuberculosis often show that both diameter are below 



50 



THE RESPIRATORY SYSTEM. 



the normal, but the antero-posterior not more so than 
the transverse. The diminution in the size of the bony 
thorax gives the chest a flattened look on account of the 
prominence of the shoulders, clavicle and scapula. A 
thorax flattened at the upper portion is of especial 
import, as it occurs most frequently in connection with 
tubercular infiltrations of the apices of the lungs. Such 
flattening at the top may be present with good or even 
relatively increased antero-posterior diameter below. 

The pathological conditions which tend to produce the 
flat type of chest are thickening of the intercostal pleura, 
which interferes with the elevation of the ribs and 

Fig. 17. 




Rachitic chest. 



Circumference = 42.75 centimetres. 
Dotted line indicates the shape of chest in an infant 
about the same age. (Gee.) 



widening of the intercostal spaces during inspiration; 
thickening of the pulmonary pleura preventing the nor- 
mal expansion of the lungs ; changes in the lung which 
diminish its elasticity, as tubercular induration, fibro- 
sis, etc., and the closure of the bronchi, which prevents 
the entrance of air into the lung. 

(3) The Rachitic Types. — In the simplest form there 
is a flattening laterally of the chest, especially in the 
lower segment; while in the upper portion the sternum 
is carried forward and the ribs are more or less straight- 
ened, so that the antero-posterior diameter of the chest 






H 






p 



O 
P» 



w 
o 




•.-•*•. 



r 




~ 

I—" 

GO 



-..^^^•.^il 



52 THE RESPIRATORY SYSTEM. 

is increased above, while the lateral diameter is dimin- 
ished below. (Fig. 16.) From this simple type the 
diameters vary up to the so-called "pigeon-breasted" 
type. (Fig. 17.) In this form the sternum is 
pushed forward; "the ribs are straightened out at 
their angle and at their junction with the cartilages," so 
that a section of the chest is nearly triangular and the 
whole contour resembles that of the breast of a pigeon. 

Rachitic chests also frequently show nodular enlarge- 
ments at the junction of the bony ribs with the carti- 
lages, which have been named the rachitic rosary. (Fig. 
18.) The depressions and peculiarities of the rachitic 
chest are due in intercurrent attacks of bronchitis in- 
volving the smaller tubes and causing interference with 
the entrance of air into the alveoli, and the production 
of a partial vacuum during inspiration. The effect of 
atmospheric pressure and the action of the diaphragm 
is to depress the soft and yielding thorax. 

Frequently, near the junction of the fifth rib with the 
sternum, and running obliquely across the chest, there 
is a well-marked depression or groove, which has been 
named the Harrison furrow. The occurrence of Har- 
rison's furrow and the deformities that occur in the 
lower portion of the chest as a result of the action of 
the diaphragm are closely related to that phenomenon 
known as Litten's sign, which will be later described. 

In the departures from normal above mentioned there 
is a certain want of symmetry between the two sides; 
but, as the changes are bilateral, they are generally class- 
ified as symmetrical deformities. 

The chest also presents unilateral or asymmetrical 
enlargement and retraction, which may affect an entire 
side or a portion only. The unilateral deformities may 
be dependent upon spinal curvatures, congenital and 
occupation deformities, swelling or oedema of soft parts-, 
or to intrathoracic changes. 

Unilateral Enlargements. — Unilateral enlargements are 
most readily seen when the patient is viewed from the 



INSPECTION. 



53 



front. On the affected side the clavicle is higher; the 
supraclavicular space may be deeper or shallower, ac- 
cording to the cause. The mammae may he displaced 
outwards, with widening of the intercostal spaces, which 
may be shallow or bulging, according to the condition 
present. From behind the spine is curved toward the 
enlarged side, and the scapula is carried outwards. 

Fig. 19. 




■'30 



Unilateral enlargement of chest (right side) artificially produced by 
injecting air into the right pleural cavity. Unbroken line: outline 
before injection. Broken line : outline after moderate distension. 
Dotted line: outline after extreme distension. Figures at bottom of 
vertical line indicate the anteroposterior diameter ; along horizontal 
line, transverse semi-diameter; remaining figures, right and left semi- 
circumference. (Gee.) 

Movement on the affected side may be increased, dimin- 
ished or absent. (Fig. 19.) Unilateral enlargement 
may be due to 

(1) Compensating emphysema. In this condition 
the lung of the enlarged side is performing more work 
than normal, and is receiving not only its own quota of 
air, but also a part of that which should be received by 



54 TEE RESPIRATORY SYSTEM. 

the opposite side. When due to this cause, the increased 
action of the muscles of inspiration are plainly visible, 
and the intercostal spaces are deepened with each inspi- 
ration; the action of the diaphragm is increased, and 
movements on the larger side are exaggerated. 

(2) General unilateral enlargement of the chest may 
be due to filling of the pleural cavity with air (pneumo- 
thorax), fluid (pleurisy with effusion), pus (empyema), 
dropsical effusions (hydrothorax) or solid tissue. " 

In enlargements due to distensions of the pleural sac 
not only is the size of the chest enlarged, but the de- 
pressions of the intercostal spaces are diminished, oblit- 
erated, or, in extreme cases, may be bulging. There is 
also marked depression of the diaphragm and protrusion 
in the epigastric region, and the movements of the 
affected side are diminished or absent, 

(3) Unilateral enlargement of the thorax may be 
induced by a lobar pneumonia affecting an entire lung. 

Care must be taken, when there is marked asymmetry 
of the thorax, in determining the relative changes that 
have taken place in the two sides, whether or not the 
enlargement of one side is absolute and abnormal, or, 
on the contrary, it appears to be larger than normal be- 
cause of unilateral diminution of the opposite side. 

Unilateral Diminution in Size. — In this condition the 
affected side is smaller in all dimensions. (Fig. 20.) 
The ribs are closer together; the intercostal spaces are 
narrowed, and may even be obliterated, or the ribs, in 
extreme cases, may overlap each other, especially in the 
lower portion. The ribs are. more oblique than nor- 
mally, giving that side of the chest a longer and 
narrower appearance. The mamma is nearer the median 
line ; the top of the shoulder is lower than its fellow on 
the opposite side; the scapula is nearer to the spinal 
column, and the spinal column is curved, the con- 
vexity looking towards the opposite side. The move- 
ments of the affected side are diminished, restricted, or 
may even be absent. The supraclavicular fossa is deeper 
than normal. 



INSPECTION. 



55 



Unilateral diminution in size may be due to (1) 
primary arrest of development, as occurs in infantile 
hemiplegia, etc., when the asymmetry is not limited to 
the thorax alone, but generally over the entire lateral 
half of the body ; and the affected side, although smaller 
than the opposite, preserves its normal physiological 
features. 

Unilateral diminution in size also occurs when there 
is atrophy or loss of function of the muscles of normal 

Fig. 20. 




Unilateral retraction of chest, consequent upon cirrhosis of left lung. 
in a girl of fourteen years. The figures indicate anteroposterior and 
transverse diameters and semi-circumferences of right and left half of 
chest. (Gee.) 

inspiration. In this condition retraction of the side 
can only occur when the condition has lasted for a long 
time, and the unopposed traction or negative pressure 
of the lung has been sufficient to cause a gradual de- 
pression of the ribs. 

(2) Diseases oe the Pleura. — Marked retraction 
of the thorax occurs in diseases of the pleura, especially 
after absorption of the fluid in pleurisy with effusion : 



53 !TBE RESPIRATORY SYSTEM. 

when changes occur in the lung or in the pleurae which 
prevent the lung thoroughly filling the thorax, as pul- 
monary collapse, fibrosis, chronic thickening of the 
pleura and adhesions of the two surfaces of the pleura. 

(3) Changes in the Lungs. — These include changes 
in the lung which cause a diminution in its size, as 
chronic interstitial pneumonia (fibrosis, cirrhosis of the 
lung), tuberculosis, interference with the entrance of air 
into the lung through narrowing or occlusion of the 
lumen of the bronchi of one lung. 

LOCAL BULGINGS. 

The asymmetry of the chest may be due to changes 
that affect a limited portion of the chest only. 

Localized enlargements may be due to (1) changes 
that occur in the soft parts, as swellings or tumors, lipo- 
mas, malignant growths, etc. 

(2) Diseases involving the bony thorax itself, as peri- 
ostitis or exostosis, fractures of the bony thorax, or from 
localized deformities clue to spinal curvature, distortion 
of the ribs, with enlargement of one side, the front of 
which is compensated for by a corresponding increase 
of the opposite side behind. 

(3) A bulging of a limited portion of the chest wall 
may be produced by a localized or encapsulated collec- 
tion of fluid or air within the pleural cavity. The 
amount of deformity that such a collection may produce 
is directly dependent upon the conditions of " the bony 
thorax, being most marked in early childhood, when the 
chest wall is soft and yielding, very slight effect or none 
being produced on the rigid chest wall of adult life. 

(4) Bulging of the thorax over the precordial space 
may occur as a result of cardiac enlargement, or of peri- 
carditis with effusion. The amount of bulging will 
depend upon the condition of the chest wall, the same as 
was mentioned above. Dilatation of the large vessels 
may also cause local bulgings, which may be attended 



INSPECTION. 57 

with visible pulsation. Local bulging of the bony thorax 
in aneurism does not occur until the pressure of the 
dilating vessel has been sufficient to cause a softening of 
the overlying bones. 

(5) Enlargements of the lower zone of the thorax 
may be caused on the right side by enlargement oi the 
liver, and on the left side by enlargement of the spleen. 

(G) General enlargement of both sides of the lower 
portion of the thorax below the fifth rib may be pro- 
duced by anything that increases the intra-abdominal 
pressure, as meteorism, ascites, abdominal tumors reach- 
ing the diaphragm, etc. 

LOCAL DEPRESSIONS OR RETRACTIONS 
OF THE CHEST. 

These may be produced (1) by diseased conditions of 
the soft parts, as local wasting in the muscles of a part. 
If there is paralysis of the muscle, so that its action 
upon the ribs is interfered with, the constant negative 
pressure that is exerted by the lung may be sufficient to 
cause a slight depression or retraction over the affected 
area. (2)" Disease of the bony structures, as rachitis. 
(3) Changes in pleura, as thickening, adhesions. (4) 
It may be dependent upon a disease of pulmonary tissue, 
as tuberculosis, fibroid induration and other pathological 
conditions which render it less distensible. 

It is necessary to have a clear idea of the factors that 
produce localized depressions in diseases of the lung and 
pleura. In normal inspiration, when the thorax en- 
larges as a result of muscular action, the distensible lung 
readily fills the cavity. When, on the other hand, a 
change, occurs within the thorax, affecting the distensi- 
bility of the pleura or the pulmonary tissue, as tubercu- 
lar infiltration or fibroid induration, on inspiration the 
affected portion of the lung does not readily enlarge, 
and as a result there is a tendency to produce a vacuum 
at the point affected. In the early stages a compensatory 
dilatation of the surrounding alveoli may make up for 



58 THE RESPIRATORY SYSTEM. 

this lack of distensibility of the lung, but, on account 
of the gradually developing muscular weakness and 
constant action of the atmospheric pressure over the 
affected part, there is produced the characteristic de- 
pression or retraction of localized intrathoracic dis- 
eases. 

These factors may cause a retraction of the entire 
side in diseases of the pleura, characterized by adhe- 
sions and obliterations of the sac after the absorption of 
the fluid in pleurisy with effusion, with atelectasis of 
the lung, and in resection of the rib. 

RESPIRATORY MOVEMENTS. 

In addition to changes that occur in the form and 
size of the chest, the movements of respiration are to be 
noted. Difficulty may be experienced in getting patients 
to breathe properly. Under examination they are apt to 
breathe abnormally, and in certain nervous individuals, 
if they are conscious of observation, it is impossible to 
get a true idea of the respiratory movement. These 
individuals should be observed without attracting atten- 
tion to your purpose. 

Normally, the movements of the two sides are equal 
and simultaneous. With each inspiration the upper 
portion of the chest is well filled out ; there is a move- 
ment upward and outward of the ribs ; an increase in 
the transverse and antero-posterior diameter 1 of the 
thorax ; the depressions of the intercostal spaces are in- 
creased, and there is a protrusion of the abdomen in the 
epigastrium, due to the descent of the diaphragm. With 
expiration the movements take place in the reverse order. 

The movements of inspiration are active, depending 
upon the action of the muscles on the bony thorax, in- 
creasing the size of the thoracic cavity with the passive 
distention of the lung. In expiration the movements 
are caused by the elasticity of the overdistended lung, 
aided by the elastic tension of the entire thorax and the 
weight of the chest. 



INSPECTION. 59 

Three types of respiration are recognized as physio- 
logical : 

(1) The costal, or superior costal, which is seen 
chiefly in women. In this type the movements of tho 
upper portion of the chest are most marked; there is 
little expansion of the lower segment of the thorax, and 
the protrusion of the abdomen is slight. In this type the 
sternum as a whole is elevated. Elevation of the 
sternum occurs both in quiet and deep breathing in 
women, but in man only in deep breathing. 

(2) The inferior costal, in which the most marked 
movement occurs in the lower six ribs, and the dia- 
phragmatic phenomena are more markedly noticed. 
This is the type of breathing normal for an adult male. 

(3) The diaphragmatic or abdominal breathing, which is 
chiefly present in children. 

In determining whether the movements of respiration 
are normal it is necessary to take into account the sex 
and age of the patient. 

Costal breathing may be abnormally increased (1) 
when the movements of the lower segment of the thorax 
or diaphragm are interfered with by oedema or inflam- 
mation of the lower lobes of the lungs, preventing their 
expansion, in which case the exaggerated co>tal breath- 
ing is compensatory. (2) Pleurisy with effusion, in- 
volving both pleural sacs. (3) Diseases of the bony 
thorax, as Pott's disease, or painful affections which 
interfere with the movement of the ribs on both sides. 
(4) Painful affections of the soft parts, although they 
rarely affect both sides. (5) Paralysis of diaphragm, 
due to bulbar paralysis, neuritis of the phrenic nerve 
in multiple neuritis, hysterical neuroses. When the dia- 
phragm does not act there is absence of protrusion of 
the epigastric region with inspiration, and it may be 
replaced by retraction, which is especially noticeable 
in hysterical paralysis and diaphragmatic pleurisv. 
(6) Diseases Moav the diaphragm with pain on move- 
ment of the abdominal organs, as peritonitis, general or 



60 TBE RESPIRATORY SYSTEM. 

local. (7) Increased intra-abdominal pressure from 
ascites, tympanites or tumors, which mechanically pre- 
vent the descent of the diaphragm. 

The inferior costal and diaphragmatic breathing may 
be increased by any condition that prevents or inter- 
feres with the normal costal breathing, as consolidation 
of the upper lobes of the lung from any cause, painful 
affections involving the pleurae, intercostal nerves, or 
bony thorax. It is especially diagnostic if it replaces 
normal costal breathing in the female adult, except in 
old age. In proportion as there is a lack of expansion 
of the bony thorax and the movement of the ribs is 
interfered with, there is a corresponding action of the 
diaphragm and diaphragmatic, or abdominal breathing. 
In old age the bony thorax becomes more rigid, and 
increased abdominal breathing is present in the female 
as well as in the male. 

The movements may be increased unilaterally when- 
ever there is interference with the respiratory function 
of the opposite side. This condition is compensatory, 
the increased action of the unaffected side making 
up as far as possible for the absence of function of the 
other. 

Increased Respiratory Movements. — The movements of 
respiration are increased in extent and number in con- 
ditions of dyspnoea, which may be clue to (1) diseases 
of the lungs which diminish their vital capacity, as 
bronchitis with exudation, consolidations of the lung 
from various causes, diseases of the pleurae. (2) 
Cardiac diseases, in which there is imperfect aeration of 
the blood from deficient circulation. (3) Diseases of 
the blood, in which its power to take up oxygen is 
diminish (anaemia). (4) Nervous diseases in which 
there is no defect in oxygenation, but rather an in- 
creased irritability of the respiratory centers. (5) In 
those diseases in which there is an increase in the elim- 
ination of C0 2 , as seen in fevers, etc. 

Distinction is made between exaggerated breathing, 



INSPECTION. 



61 



or increased motion, in which the ordinary muscles of 
respiration only are involved, and labored breathing, 
where the extraordinary muscles of respiration are 

called into play. 

Diminished respiratory movement may be bilateral, 
unilateral or local, and may occur as a result of (1) dis- 
eases of the muscles of respiration, (2) painful condi- 
tion of soft spots, (3) diseases of the bony thorax, (4) 
diseased conditions of the pleurae or (5) diseased con- 
ditions of the lung, either general or local. 

Bilateral diminution, or absence of motion, occurs 
when there is disease of the bony thorax, especially 
Pott's disease, preventing a normal movement of the 
ribs. Also in diseases involving the intercostal nerves 
and muscles. It is present, with enlargement of the 
thorax, when both pleural cavities contain air or fluid ; 
when the elasticity of the lung is diminished, as in 
emphysema; after absorption of fluid in pleurisy or 
empyema ; with thickening and adhesion of the pleurae 
in diseases of the lungs which prevent or interfere with 
this expansion. 

Whenever there is difficulty or interference with the 
entrance of air in the lung, through narrowing or occlu- 
sion of the upper air-passages or bronchi, as a result of 
forced inspiratory effort, there is a marked depression 
of the lower portion of the thorax, due to the partial 
vacuum that is produced. Not only is motion inter- 
fered with, but the number of respirations is diminished. 
Unilateral and local diminution of motion varies in 
degree from slight lagging to entire absence of motion 
and may be due to loss of muscular power, to painful 
conditions of the muscles (inflammation, neuralgia) of 
the bony thorax (periostitis, fracture of ribs, etc.), to 
diseased conditions of the pleurae (acute pleurisy, pain- 
ful and catchy breathing), or increased thickness and 
adhesions preventing movement of ribs and expansion 
of lung. These conditions are associated with unilateral 
and local retraction. When the pleura contains air and 
fluid, loss of motion is associated with increase in size. 



62 THE RESPIRATORY SYSTEM. 

LITTENS PHENOMENON. 

In addition to the protrusion of the epigastrium, 
Litten has called attention to the effect that descent of 
the diaphragm has on the lower portion of the chest. 
If a person who is not too fat is so placed that lying on 
his back the light fall upon the chest from the direction 
of the feet only, the observer, standing at the side, 
notices a narrow shadow moving downward when a full, 
deep breath is taken. This shadow is due to expansion 
of lower ribs, caused by the slow separation (by the 
descent of the diaphragm) of the two surfaces of the 
pleura over the so-called complemental spaces and the 
gradual extension of the lower border of the lungs, with 
filling out of the intercostal spaces. 

The phenomenon is modified or absent in all condi- 
tions that (a) change the normal relation of the two 
surfaces of the pleura in the complemental space, viz., 
effusion of the pleural cavity; (b) or interfere with the 
descent of the diaphragm, as adhesions of the two sur- 
faces of the pleura; or (c) prevent the lung from dis- 
tending, as pneumonia of the base of the lung, pulmo- 
nary emphysema, fibroid induration and tubercular in- 
filtration, especially of the apex. 

Litten's phenomenon is often of value in diagnosing 
slight pleuritic effusions from enlargements of the liver 
and spleen, as subdiaphragmatic conditions do not inter- 
fere with the descent of the diaphragm, unless attended 
with pain or greatly increased intra-abdominal pressure. 

ALTERATIONS IN FREQUENCY. 

Rapidity of respiration varies normally with age. 
Under one year of age it is 44 per minute ; one to five 
years, 26; five to twenty years, 20, and after twenty 
years of age the average rapidity is 18. Physiologi- 
cally, it is influenced by posture, exercise, digestion and 
by mental influence. In diseases of the respiratory 
tract the rate is increased in proportion to the inter- 



INSPECTION. 63 

ference with the aerating function of the lungs. The 
rate in diseases of the lung is never decreased, except 
laryngeal or tracheal stenosis and asthma. 

Diminution in the rate of respiration is otherwise 
dependent upon some influence acting on the nervous 
system, and especially on the respiratory center. 

ALTERATION IN RHYTHM. 

Normally, the movements of breathing are in perfect 
rhythm, each respiratory act being of equal length and 
depth and following each other without any appreciable 
pause. The movement of inspiration is slightly shorter 
than that of expiration, the ratio being as 5 to 6. As 
age advances this ratio becomes slightly greater, due to 
the impaired elasticity of the lung, so that in the aged a 
ratio of 5 to 8 is not unusual. 

In asthma and emphysema the rhythm is disturbed in 
proportion to the expiratory difficulty, so that the move- 
ment of inspiration may be short, spasmodic or jerky, 
while expiration is slow, prolonged and incomplete. 

When obstruction of the upper air-passages (intra- 
laryngeal or intratracheal growths, false membranes, 
etc.) produce inspiratory dyspnoea, then the inspiratory 
movements are prolonged and the breathing is slow. 

The rhythm is also disturbed when the respiratory 
movements cause pain (intercostal neuralgia, pleuro- 
dynia, pleurisy, etc.), and, as the pain is most intense 
at the time of greatest motion, the inspiration is short, 
shallow and catching and expiration slow and feeble. 

A peculiar disturbance of rhythm has received the 
name of "CheynehStokes" breathing. The movements 
are unequal and arhythmical, but follow a fixed cycle. 
One or two shallow respirations are followed by four or 
five that progressively increase in frequency, depth and 
noise until the acme is reached, and then gradually sub- 
side in inverse order. This is followed by a longer or 
shorter respiratory rest or "pause" (apnoea), which is 
followed by another attack of disturbed breathing. 



64 THE RESPIRATORY SYSTEM. 

This type of breathing occurs in severe types of 
cerebral, cardiac and renal diseases and narcotic poison, 
and is generally an unfavorable symptom. 



CHAPTER III. 

PALPATION. 

By palpation we obtain information by the sense 
of touch, or tactile sense, and it is usually the second 
step in the examination of the respiratory and circula- 
tory organs. 

While it confirms all that has been learned by inspec- 
tion, it is in many respects more definite and exact, and 
increases the evidence that has already been obtained 
by the eye, for it determines the presence or absence of 
certain vibratory phenomena and allows of differential 
diagnosis between conditions that produce similar 
changes in the shape and movements of the thorax. 

As inspection furnishes results of a general character, 
so also does palpation, and, on account of the ease with 
which it is performed, we often substitute it for inspec- 
tion where that is impossible on account of the posture 
of the patient to view the chest. 

The results obtained by palpation depend upon the 
sensitiveness of the observer's sense of touch {tact is 
cruditus), and whether or not the chest is examined in 
a methodical and svstematic manner. 

Every part of the thorax should be examined, and 
those who claim that palpation is of minor importance 
are either deficient in the sense of touch or employ it 
in a haphazard manner without attention to details. 

In performing palpation the surface should be bare, 
so the hand can be applied directly to the skin. It is 
not necessary to expose the thorax to view, as the hand 
can be slipped under a loose covering. At times it may 
be necessarv, on account of a. feeling of delicacv on the 
part of the patient, to have a thin covering, as gauze, 

5 



66 THE RESPIRATORY SYSTEM. 

between the surface and the hand ; but even this inter- 
feres, to a certain extent, with the examination. The 
hands of the examiner should be warm, so as not to be 
unpleasant to the patient. 

Attention should be paid to the position of the 
patient, and the examiner should always bear in mind 
that want of symmetry is a matter of greatest impor- 
tance, so that the two sides should be compared region 
by region, as each portion of the chest gives its own 

evidence. 

By palpation of the thorax, with reference to the 
respiratory organs, knowledge is gained of the follow- 



ing: 



(1) SIZE, SHAPE AND SYMMETRY OF THE THORAX. 

Palpation gives very little information on these points 
beyond what can be gained by inspection, and in most 
cases it is not as accurate in regard to symmetry. When 
inspection is impossible, on account of not being able to 
expose the chest, we gain a fairly accurate knowledge 

by palpation. 

' One important fact noted by palpation is the location 
of the different ribs. Eemember that the second rib is 
the one below the clavicle that can be taken between the 
fingers ; it corresponds with the ridge on the sternum. 

(2) RESPIRATORY MOVEMENTS. 

As its object is to test if the movements of the two 
sides are simultaneous and equal, it is necessary that 
the hands be placed, at the same time, over correspond- 
ing regions of the chest for comparison. 

As the time, extent and rhythm of the respiratory 
movements are to be examined, also whether the widen- 
ing of the intercostal spaces occurs equally on both sides, 
the hands must be so placed as to note these points. 

To palpate the anterior surface of the chest, the exam- 
iner stands behind the patient and places the hands over 



PALPATION. 67 

the chest so that the fingers are parallel with the ribs, 
resting in the intercostal spaces. By these means a 
better perception of motion and of time is obtained. To 
palpate the posterior surface, the position is reversed. 

The anteroposterior movement of the chest is noted 
by placing one hand over the sternum in front, and the 
other posteriorly over the spine. 

The movement of the clavicle and upper ribs is 
observed by placing the hand over the shoulder, the 
fingers resting on the anterior portion of the chest, and 
the thumb behind on either side of the spine. 

The examiner should remember that the respiratory 
movements are influenced by age and sex, as already 
explained under "Inspection." 

Slight inequality of motion between the two sides, as 
shown by a slight lagging of one side, when present in 
the slightest degree, is detected by the expert palpator, 
and is of diagnostic importance. 

Under "Inspection" attention was called to Litten's 
phenomenon. The movement of the diaphragm that pro- 
duces it can be felt as well as seen, and gives us impor- 
tant evidence of any change in the movement of the 
diaphragm. 

Palpation is almost as sensitive as the fluoroscope in 
detecting slight changes in diaphragmatic movement. 

(3) VIBRATORY PHENOMENA. 

Vocal fremitus, also called tactile and tussive fremi- 
tus, are the vibrations that are felt by the hand on the 
surface of the chest when the air contained in the lungs 
is thrown into vibrations sufficiently strong to be trans- 
mitted to the thorax and recognized by the sense of 
touch. The vibrations of ordinary respiration are too 
feeble to be appreciated by the hand, while they are 
recognized by the ear and termed normal vesicular 
murmurs, or breath sounds. 

In order to obtain vibrations sufficiently powerful the 
voice is used. The movements of the vocal cords set 



68 THE RESPIRATORY SYSTEM. 

up corresponding vibrations in the air contained in the 
lungs, which are transmitted through the thorax and 
appreciated by the hand on the surface of the chest, 

Vibrations set up by the voice are not of equal 
strength for all persons/ varying according to the voice, 
sex and age of the individual. The wave length in man 
is from 8 to 12 feet; in women, 4 to 6 feet, while in the 
child the wave length is so short and the vibrations so 
rapid as to render vocal fremitus indistinct. 

As the character of the vibrations produced by the 
voice modify the vocal fremitus that is obtained, it is 
necessary that the vocal vibrations be as equal and as 
uniform as possible. For this reason the patient is 
usually instructed to count 1, 2, 3 or use some phrase, 
as 99 or 44. Any monotone may be employed to set up 
the vibrations. 

It must be borne in mind that each individual will 
have a vocal fremitus which will have a direct relation 
to the character of his voice. Voices that are low-pitched 
and heavy, as in man, give a correspondingly strong 
vocal fremitus ; while, on the other hand, the thin, weak 
or high-pitched voice, as in woman, being an octave 
above that in man, gives a correspondingly weak vocal 
fremitus, which in some cases may be so faint as not to 
be detected by touch. 

The vibrations produced in the larynx do not reach 
all portions of the surface of the chest with equal in- 
tensity. We note that it is stronger over the rigth lung 
than over the left; that it is more marked over the right 
apex than over the left. 

The reason for this difference in intensity is explained 
by the anatomical arrangement of the primary bronchi 
on the two sides and their relation to the trachea. The 
bronchus going to the right lung is more nearly a con-: 
tinuation of the trachea, has a greater lumen, and leaves 
the trachea at a less acute angle, so that the vibrations 
that are set up in the larynx reach the entire right lung 
with greater force on account of the larger column of air 
contained in the bronchi. 



PALPATION. 



69 



Vocal fremitus over the apices of the two lungs differ, 
being more intense on the right side. 

This physiological increase of vocal fremitus on the 
right side often misleads the observer, as its intensity 
may suggest a pathological condition of the lung. 

The cause of this marked increase of vocal fremitus 
over the apex of the right lung is due to the fact that 
the bronchus supplying the upper lobe is given off from 

Fig. 21. 




Diagram showing the relation of the trachea and bronchi to the 

anterior chest wall. 



the primary bronchus closer to the trachea, and the 
vibrations conveyed to the upper lobe of the right lung 
are correspondingly stronger. Whether or not an in- 
creased vocal fremitus over the right upper lobe is patho- 
logical can only be determined by considering other 
signs in connection with it. 

The nearer the bronchi approach to the surface of the 
lung, and the larger their lumen, the more distinct will 



70 THE RESPIRATORY SYSTEM. 

the vibrations be felt. For this reason the vibrations are 
stronger over the upper portion of the thorax, between 
the scapula behind, especially on the right side, and at 
the junction of the second intercostal spaces on the right 
side and the third on the left, (Fig. 21.) 

The further the surface of the chest is removed from 
the larynx and trachea, the smaller the bronchi that sup- 
ply the portion of the lung immediately underlying it, 
the greater the proportion of pulmonary tissue to the 
bronchi, the weaker will be the vibrations that are con- 
veyed from the larynx to the surface of the chest, and 
consequently the vocal fremitus that is felt over the 
lower portion of the thorax and the borders of the lung 
is much weaker than over the large bronchi. 

In addition to the influence of the pulmonary struc- 
ture, the vocal fremitus is modified by the condition of 
the chest wall; and according to the law that vibrations 
are lost in passing through media of different densities 
and especially when passing from a media of a lesser to 
one of a greater density, vocal fremitus will be weak 
over those portions of the chest where a large amount of 
tissue intervenes between the hand and the pulmonary 

structure. 

This is especially marked over the mammae in women, 
over the scapula behind and is uniformly modified over 
the chest when the soft parts are greatly increased in 

thickness. 

It is very necessary that the examiner should bear in 
mind the normal variations of vocal fremitus that occur 
over different regions of the chest, and that he thor- 
oughly familiarizes himself with their relative intensity. 

In examining for vocal fremitus the whole hand is 
placed lightly upon the chest, so as to get a relative idea 
of the vibrations over the point that is examined. It 
will make a difference whether the fingers are placed in 
the intercostal spaces, as in testing for the respiratory 
movement, or on the ribs and bony thorax. 

When the fingers are placed between the ribs, then 



PALPATION. 71 

the vocal fremitus that is felt is transmitted from the 
pulmonary tissue directly through the thm covering ol 
the intercostal spaces, while if the hand is placed upon 
the ribs, or, as is usually done, across the ribs and 
intercostal spaces, then the vibrations that are felt are 
not those that are conveyed to the surface by the portion 
of the lung immediately under the hand, but are all the 
vibrations that have been brought to the surface and 
have been taken up by the bony thorax, which acts as a 
sounding board. m . , 

In order to examine for vocal fremitus m a limited 
area, it is best to place the tips of the fingers or edge ol 
hand only upon the chest in the intercostal spaces while 
the patient is speaking. In this way slight local varia- 
tions may be readily detected. 

When the hand is placed over the shoulders, the 
thumb resting behind and the tips of the fingers beneath 
the clavicle, we obtain an idea of the relative intensity 
of the vocal fremitus that is produced m the entire 
upper portion of the thorax. 

Vocal fremitus may be increased, diminished or 

absent. , -, 

Vocal Fremitus Increased.— As was seen above, under 
Normal Variations in Vocal Fremitus, the vibrations 
that are made in the larynx are modified by the con- 
ducting power of the lung, and are normally weakened 
as they pass from the larger to the small bronchi, and 
from these to the alveoli. 

As the "spongy" condition of pulmonary tissue inter- 
feres with the transmission of vibration, so, on the other 
hand, any condition which renders the lung more homo- 
geneous gives an increased power of conduction and 
consequently increases vocal fremitus. 

Increased vocal fremitus is obtained in all pulmonary 
consolidations, such as those of pneumonia, tubercular 
infiltration, infarction or fibroid thickening of the lung; 
and the amount of vocal fremitus is directly dependent 
upon the changed anatomy of the lung and its increased 
power of conduction. 



72 THE RESPIRATORY SYSTEM. 

As the vibrations that are brought to the surface are 
transmitted through the columns of air contained in the 
lung and the pulmonary structures, the tension of the 
lung tissue will modify the transmission of these vibra- 
tions. 

Increase of tension increases the ease with which the 
vibrations are carried from one portion of the lung to 
the other, and also increases the rapidity of the vibra- 
tions themselves. 

Increase of tension is present in pulmonary conges- 
tion, causing a slight increase in vocal fremitus. 

In children, in addition to the high-pitched voice, 
with its attendant rapid vibrations, the tense pulmonary 
tissue causes the vibrations to become so rapid as to be 
indistinct. 

Increased vocal fremitus is felt over cavities in the 
lung, as the vibrations from the larynx, trachea and 
bronchi are transmitted direct through the large air- 
containing spaces to the surface of the chest. 

Diminished or Absent Vocal Fremitus. Changes Due 
to the Bronchi. — As the vibrations are conveyed 
chiefly through the columns of air in the bronchi to the. 
surface of the lung, anything that diminishes the lumen 
of the tube will interfere with the transmission of the 
vibrations from the larynx in direct proportion to the 
diminution in size. If it is occluded, aerial vibrations 
are arrested and there is an absence of vocal fremitus 
over the area supplied by the occluded bronchus. 

Vocal fremitus may be diminished through narrow- 
ing of the lumen of the tube in bronchitis and asthma, 
and may be entirely interfered with in plugging of the 
bronchi as occurs in fibrinous bronchitis, in pneumonia, 
or by the growth of tubercle nodules ; and also by occlu- 
sion of the tube by pressure, as in aneurism. 

Changes Due to Pulmonary Tissue. — Just as 
tense pulmonary tissue by being more readily thrown 
into motion by the air in the bronchial tubes increases 
the amount of vocal fremitus, so all conditions which 



PALPATION. 73 

render the lung tissue less tense interfere with the trans- 
mission of vibrations to the surface by smothering or 
dampening the vibrations conveyed to it. This is 
especially noticeable with loss of elasticity and negative 
pressure in emphysema, while, on the other hand, it 
does not occur in compensatory emphysema where the 
tension of the pulmonary tissue is increased, as in this 
condition the vocal fremitus may be normal, the increase 
of tension in the pulmonary tissue counterbalancing the 
increased sponginess from dilation of the alveoli. 

Influence of the Pleura. — Ordinarily the normal 
pleura, on account of its extreme thinness, has no influ- 
ence on vocal fremitus. When, however, the pleura is 
thickened or it contains effusion of any kind it inter- 
feres markedly with the transmission of the vibrations 
from the lungs, according to the law that vibrations arc 
lost when they pass from a rarer to a denser medium, 
and the amount lost, ranging from a slight diminution 
in intensity to total absence, will be in direct proportion 
to the amount of thickening or fluid that is contained 
within the pleural cavity. 

The conditions of the pleura which interfere with the 
transmission of vibrations are: (1) Pleuritic thicken- 
ing, which may be due either to primary pleurisy or be 
dependent upon tubercular infiltration : (2) Exuda- 
tions upon the surface of the pleura, as occurs in acute 
pleurisy with plastic exudation: (3) Effusion into the 
pleura, whether serous, sero-fibrinous or purulent. The 
specific gravity of the fluid does not alter to an apprecia- 
ble degree the transmission of vocal fremitus. (4) 
When the pleural cavity contains air, as in pneumo- 
thorax, the vocal fremitus is interfered with, because 
the relaxed lung is a poor conductor of vibration. 

Influence of the Chest Wall. — Increase in the 
thickness of the soft parts will diminish vocal fremitus, 
according to the law that vibrations are lost in passing 
from a rare to a dense medium, but not to the same 
degree as a corresponding thickness of the pleura. 



74 TEE RESPIRATORY SYSTEM. 

The reason for this is that when the pleura is thick- 
ened the vibrations are smothered or suppressed before 
they can be conveyed to the bony thorax, which acts as 
a sounding board and overcomes to a certain degree the 
inertia of soft (thickened) tissues of the chest wall. 

This diminution will be most marked if the source 
of vocal fremitus, namely, the voice, is of such a nature 
as to give normally a feeble vocal fremitus. 

Rhonchi and Palpable Rales —In addition to the vibra- 
tions that are produced by the voice, the air passing 
through the liquid secretion in the bronchi is frequently 
thrown into vibrations sufficiently strong to be conveyed 
to the chest wall as fremitus. On account of being made 
in the bronchi, they have been named bronchial rhonchi, 
or palpable rales. 

They occur chiefly with inspiration, and are most fre- 
quently felt in children ; and are usually associated with 
noisy or asthmatic breathing, but the ordinary sibilant 
or sonorous rales of asthma are so high-pitched and the 
vibrations are so rapid that they are not detected by 

sense of touch. 

Friction Fremitus.— Ordinarily the surface of the se- 
rous membranes glide over each other without friction. 
When, however, there is a marked roughening of the 
two surfaces, then their movement may be attended 
with vibrations sufficiently intense to be felt on the 

surface. 

Friction fremitus is most commonly felt at the point 
of greatest motion of the serous membranes,^ normally 
in the axillary space over the fifth and sixth ribs. 

Splashing or Succession Fremitus.— When air and fluid 
are contained in the pleural cavity, and rarely in large 
cavities in the lung lying close under the pleura, on 
coughing or violent shaking of the chest the motion of 
the fluid contents may be sufficient to be felt on the sur- 

Pain. — In addition to the vibratory phenomena, it is 
possible to determine by palpation whether or not pain 
is present. 



PAL PAT I OX. 75 

Pain on palpation may be due to a sensitive condition 
of the chest wall itself, as is seen in the tender spots of 
Valleux, in inflammatory conditions of the muscular 
tissue and in diseased conditions of the bony thorax, as 

periostitis, etc. 

An important variety of pain elicited by palpation is 
interpleural. In order to test for this it is necessary 
that the pressure be made so forcibly as to interfere with 
local expansion of the chest and bring the two surfaces 
of the pleura into close contact. The sign is valuable 
in tubercular involvement of the pleura over the apex. 
It is obtained by standing behind the patient, bringing 
the hands over the shoulder, as in testing for vocal fremi- 
tus, and making firm pressure with tips of the fingers in 
the infraclavicular fossa. 

Frequently it is possible to obtain this slight sign 
when no pleuritic rales can be detected by auscultation. 

The test for pain, and especially interpleural pain, 
should be left till the last, as, if it is performed earlier 
in palpation, it is apt to disturb the rhythm and move- 
ment of the thorax, and so lead to false impressions. 

Fluctuation.— By palpation we also determine the 
consistency and elasticity of tumors and enlargements 
of the chest that have been noted on inspection. 



CHAPTER IV. 

PERCUSSION. 

Percussion in physical diagnosis is the act of strik- 
ing the body in order to elicit sound by setting up 
vibrations. 

If the tissues that are percussed are solid, as the 
thigh, the sound produced will be dull, and is described 
as toneless, flat or dead. If, on the other hand, it con- 
tains gas or air, as the thorax or abdomen, it gives out a 
sound that has resonance or tone and the elements of 
sound — (1) quality or timbre, (2) intensity or volume, 
(3) pitch, (4) duration or length — will be present and 
easily recognized by the ear. 

It is necessary to consider the elements of sound in 
detail, so as to appreciate their value in the percussion 
of the thorax. 

The quality or timbre of a sound is "that character- 
istic by which the sound produced from some particular 
source, as from an instrument or voice, may be dis- 
tinguished from sounds from other sources, instruments 
or voices. " 

It is physically dependent upon the form of the vibra- 
tions by which the sound is produced, and although the 
pitch, intensity and duration may alter, the quality still 
indicates the source of the sound. 

The quality of the sound produced by percussion over 
lung tissue is called pulmonary or vesicular resonance. 

The intensity or volume of sound depends upon the 
amplitude or extent of the vibrations. It varies directly 
as their square, and is further modified by the force of 
the blow. 

The intensity is influenced in pulmonary percussion 



PERCUSSION. 77 

by the amount of the air-containing tissue that is set in 
motion. It is also modified by the surrounding tissues, 
whether or not they are easily thrown into vibration 
when struck and so impart motion readily to the con- 
tained air. Therefore in the percussion of the thorax 
the intensity of resonance is influenced by the condition 
of the chestwalls, bony thorax and pulmonary tissue. 

The innuenceof the force of the blow, the amount of 
air contained and the nature of the covering is readily 
illustrated in the drum. While the quality of the sound 
does not change, the intensity or volume is directly in 
proportion to the force of the blow upon the drum head. 
The pitch depends upon the rapidity and length of 
the vibrations. The shorter and more rapid the vibra- 
tions, the higher the pitch. This is well illustrated in 
the fiddle string or drum head. The pitch become:, 
higher when the tension of the vibrating medium is 
increased and is lowered by relaxing it. 

The pitch is the most difficult part of a sound to 
appreciate, because the ear does not detect slight varia- 
tions in pitch as readily as changes in quality, intensity 
or duration, and it is only by training the ear that the 
finer changes in pitch are recognized. 

Beainners are confused by the fact that high pitch is 
most frequently associated with dullness and therefore 
it seems impossible to distinguish between a high-pitched 
note which is dull or characterless, as is obtained over 
consolidated lung, and a resonant, clear note that is also 
high pitched, as'occurs over distended lung tissue with 
increased tension. 

Within certain limits, pitch varies in the lung accord- 
ing to the tension of the tissues, but as this is slight it can 
only be considered in connection with the other elements 

of sound. 

The pitch of the percussion note over normal lung 
tissue is low, varying within narrow limits in different 

individuals. 

As pitch depends not only upon the rapidity and 



78 THE RESPIRATORY SYSTEM. 

length of the vibrations of the air in the pulmonary 
tissue, but also upon the facility with which the vibra- 
tions pass through the tissues, the different notes we 
obtain in percussion of the thorax are modified by the 
soft parts of the chest, the bony thorax and the patho- 
logic conditions in the pleura and pulmonary tissue. 

From a diagnostic standpoint, variation in pitch is 
the most important of all changes that occur in the per- 
cussion sound, as it shows the physical condition of the 
part percussed. 

The duration of sound depends upon the length of the 
waves and their persistence, and varies directly with 
the pitch and intensity. 

Fig. 22. 

Flatness. 

Dull tone. 

Tracheal or tubular tone. 
Resonant tone. 

.Tympanitic tone. 
Volume and duration. 
Diagrammatic sketch of the relations of the elements of tone. The perpen- 
dicular line represents the pitch. The transverse line the 
volume and duration. 

The elements of sound have a definite relationship to 
each other. (Fig. 22.) Sounds that have the highest 
pitch have the least intensity and minimum duration 
and resonance. Such a sound is described as flat or 
airless. 

As the pitch becomes lower the intensity increases, 
duration lengthens, quality of resonance becomes more 
marked and the sound is described as dull, resonant or 
tympanitic, according to the pitch. 

Normal pulmonary resonance has a quality character- 
istic enough to be easily recognized although impossible 
to describe, low pitch, great intensity and duration. 




PERCUSSION. 



79 



It is this combination of the elements of sound that 
is described by the "clearness" of the note. 

As these elements vary the different pathological 
types are produced. 

METHODS OF PERCUSSION. 

In order to elicit sound from the air-containing spaces 
of the lungs by percussion, vibrations are set up in the 
chest in a number of different ways. 

(1) Immediate, or Direct Percussion. — This was first used 
by Auenbrugger, in 1761. In this method the blow 
is struck directly upon the chest wall, generally over 
the bony structures. The sound produced is chiefly 
that made by striking the bony thorax, and its value 
is to show the ease with which the thorax itself is thrown 
into vibration. Light immediate percussion over the 
clavicle is especially sensitive in showing slight differ- 
ences in resonance at the apex of the lung in beginning 
tuberculosis when no change can be detected by mediate 

percussion. 

(2) Mediate, or Indirect Percussion. — In this method 
the blow is struck not directly upon the thorax, but upon 
some interposed medium, which is called the pleximeter. 
In this country a finger of the left hand, either the index 
or the second, is generally used as the pleximeter. but 
some examiners use in its place pleximeters made of 
various substances, as ivory, wood, celluloid or other 
material that has a certain amount of elasticity. ^ 

It is important that the student become familiar with 
a single method. If he is constantly substituting for 
the finger the ivory or wood pleximeter, he does not 
become^proficient in any one method, and is confused by 
the sounds elicited. Ordinarily one of the hardest 
things for the student to ignore in percussion is the 
sound produced by striking the pleximeter, which in 
instruments made* of ivory, etc., is especially marked, 
and is one of the chief objections to their use. 

The finger, on the contrary, has a structure homo- 



80 THE RESPIRATORY SYSTEM. 

genous with that of the thorax and does not add a new 
quality to the percussion note. After a certain amount 
of practice this sound is ignored and only that which 
is elicited from the deeper portion of the thorax noted. 
As a pleximeter the fingers give a wider range in size 
and shape and readily adapt themselves to the surface 
of the thorax. 

It is a matter of choice which finger of the left hand 
is selected for this purpose, as all have been advised, 
but whichever is selected that one should always be 
used. The other fingers and the hand should be raised 
from the chest so as not to dampen the vibrations. The 
finger used should be applied firmly enough to hold the 
soft parts in place and to leave no space between the 
finger and the soft parts, as this will give an impure or 
"cracked-pot" sound. 

In addition to the above advantages the finger also 
allows the examiner to note the resistance of the tissue 
percussed and any lack of vibration, so that in per- 
cussing the chest one frequently feels more than he 
hears. 

Accurate comparative percussion requires that the 
finger be applied to corresponding spots on the two sides. 
If percussion on one side is over the rib or interspace it 
should be made over the same tissues on the opposite 
side and the same amount of pressure should be used. 

To obtain the purest pulmonary resonance the finger 
should not be placed upon the bony thorax, but in the 
interspace. The reason for this will be considered 
later. 

That with which the blow is struck is called the 
plessor. For this purpose may be used the finger or 
• fingers of the right hand, or a small hammer of ivory, 
wood or some other elastic substance. Many types of 
hammers have been advised, and the virtues of each one 
has been extolled by the inventor, but all are inferior 
to the finger, although proficiency in finger percussion 
is harder to attain, and demands no little practice. Ordi- 



PERCUSSION. 



81 



narily the failure to appreciate the value of percussion 
as a means of diagnosis is due to imperfect technique. 
The fingers are bent in a crooked and uneasy position ; 
the whole arm is then moved, and the blow is struck 
from the elbow. This blow is necessarily a heavy one, 
and, on account of the infrequency with which it is 
struck and the length of time that the percussing finger 
rests upon the pleximeter, suitable vibrations are not set 
up in the chest wall. 

Fig. 23. 




Showing position of fingers in percussion. 

To get the clearest sound it is necessary that the 
fingers be bent from the second joint, so that the tips of 
the fingers are even, and they must strike squarely and 
quite vertically upon the pleximeter. The blow should 
be struck entirely from the wrist, and should be a short, 
sharp tap, the percussing finger or fingers resting but a 
short time upon the finger struck. (Fig. 23.) Light 
percussion can be performed by a motion of the finger 
only. Care should be taken by the beginner that the 

6 



82 



TEE RESPIRATORY SYSTEM. 



nail of the hammer finger does not strike directly upon 
the underlying finger. The blow should be struck with 
the rounded end of the finger, just as it curves to meet 
the palmar surface. 

A good way of obtaining the wrist motion is by plac- 
ing the entire arm flat upon the leaf of a table and strik- 
ing it from the wrist from forty to eighty times a 
minute. (Figs. 24 and 25.) The resonant table leaf 
readily shows by the sound any variation in the force or 
frequency of the blow. It is well also for the student to 

Fig. 24. 




stand close to a wall, facing it, and, applying the arm 
to the wall, perform the same motions, so as to accustom 
himself to percussing in different positions. 

The rapidity with which the blow is struck has a 
marked influence upon the amount of sound produced. 
In certain cases single blows, with long intervals be- 
tween, are used for the purpose of determining the ease 
with which the thorax is thrown into vibration. When 
they are struck with medium rapidity (but not less than 
forty to the minute), the vibrations reach the deeper 
portion of the lung with equal strength and a clear note 



PERCUSSION. 



83 



is obtained. When the blows are struck too rapidly 
there is an accumulation, so to speak, of vibrations and 
there occurs an interference of the sound waves. 

The force of the blow should be the same over corre- 
sponding portions of the two sides. 

A correct position for the patient is almost as impor- 
tant as the technique of the operator. The surface 
should be bare, but if this is undesirable then the cover- 
ing should be as thin and soft as possible Males do 
not object to being stripped to the waist for examination, 

Fig. 25. 




but in the female, and especially the young, it is best to 
have the surface protected by a soft, thin, "smooth dress, 
sack or shawl. 

Whether standing, sitting or lying, the patient should 
assume a perfectly easy and natural position, with the 
muscles relaxed and the positions of the two sides sym- 
metrical. While the standing posture is the most conve- 
nient for the examiner, it is best to examine patients 
who are weak in either the sitting or lying position, as 
the pressure of the finger on the chest is apt to cause 
them to sway, or to prevent this they brace themselves 



84 THE RESPIRATORY SYSTEM. 

and so cause uneven tension of the muscles of the two 
sides. In examining patients in bed, care should be 
taken that the body is straight and the shoulders not un- 
evenly placed. . . . 

It should be remembered that when the patient is m 
bed and surrounded by pillows the character of the per- 
cussion sound will be somewhat changed, being slightly 
muffled ; also that the percussion outline of the organs is 
modified by their "passive mobility." > 

When percussing the front of the thorax with the 
patient standing or sitting the arms should hang easily 
at the side, and the head should be held straight m the 
median line. The patient, in order to avoid breathing 
in the examiner's face, frequently turns the face sharply 
to one side, rendering percussion above the clavicle ditti- 
cult and the resulting tension of the muscles changes the 
sound of the two sides. To percuss the axillary space, 
the arm should be moved slightly backward or raised at 
a right angle to the body with the hand resting on the 
heacl so as to relieve the tension of the muscles. 

When percussing the back, as the heavy muscles and 
scapula interfere, the shoulder blades are carried forward 
toward the axillary space by folding the arms across the 
chest, with the tips of the fingers resting on opposite 
shoulders. Or, when sitting, the arms may hang loosely 
between the knees, allowing the shoulders to drop for- 
ward as much as possible. These positions uncover a 
large portion of the thorax, and the line of the scapula 
corresponds to the lower border of the upper lobe and 
interlobular septum. 

CONDITIONS MODIFYING PERCUSSION SOUND. 

As the object of percussion is to elicit sound from the 
deeper portion of the thoracic cavity it is necessary to 
consider the influences that the different structures have 
upon the vibrations that are set up. 

(1) Influence of the Soft Parts.— The ease with which 
the soft parts are thrown into vibration depends largely 



PERCUSSION. 



85 



upon their structure. Muscular tissue, on account of its 
tension, is easilv influenced, so that with the bonv thorax 
chiefly covered with muscle, vibrations are readily con- 
veyed to the deeper portions of the chest. Over that part 



Fig. 20. 




1, 2 and 3 represent the difference of result of percussion notes of 
equal strength, but with different body thicknesses. 3 and 4 show how, 
by increasing the force of the blow, lung resonance is obtained. 



86 THE RESPIRATORY SYSTEM. 

of the thorax where the muscle tissue is heavy, blows that 
would be sufficient to set up vibrations in the air-contain- 
ing spaces below the thinly covered portion are absorbed 
by the heavy muscle and no sound is heard. 

Adipose tissue, on account of its lack of elasticity, is 
thrown into vibration with difficulty, while oedematous 
tissue is the most difficult of all to influence by ordinary 
percussion. The effect that the soft parts have upon 
vibration is clearly shown in Fig. 26. 

In order to overcome this interference of the soft 
parts with the transmission of vibration, it is necessary 
that the percussion be more forcible, as shown in Fig. 26. 

It is thus easily perceived that percussion of the same 
strength will not elicit the same sound over all portions 
of the chest irrespective of the condition of the lung 
itself. Where muscle or adipose tissue. is thinnest a 
fairly good pulmonary resonance may be obtained with 
light percussion, while, on the other hand, where the 
muscle or fat is thick, as over the mammsc and the heavy 
muscles of the back, very forcible percussion is neces- 
sary, and the sound obtained is the dull high-pitched 
note of the solid structures, with little pulmonary 
resonance. 

The. student must be on his guard to differentiate 
between dull high-pitched notes that are obtained by 
percussion over the thick soft parts from the dullness 
that is due to intrathoracic changes. 

(2) The Influence of the Bony Thorax. — Bony tissue, 
when thinly covered, gives a peculiar note of its own 
when struck. The bony thorax is easily thrown into 
vibration, and if the blow be struck upon a rib the vibra- 
tions that are set up are not only transmitted to the 
viscera underneath but are conveyed along the ribs to 
the sternum and other bony portions of the thorax. 

The readiness with which the bony thorax takes up 
vibrations must also be considered in the force of the 
blow. If the blow is very forcible the whole of one side 
of the thorax may be thrown into vibration, and instead 



PERCUSSION. 87 

of obtaining sound from the portion immediately under^ 
neath the part struck vibrations are obtained from the 
whole of the thorax, the sternum acting as a sounding 
board. Forcible percussion over the clavicle, on account 
of the conveyance of the vibrations to the sternum^ and 
through it to the general thorax, is used merely to indi- 
cate the condition of one side of the chest as compared 
with the other and is of little value as indicating the con- 
dition of the tissue immediately underneath it. A 
marked consolidation of one lung or a collection of 
fluid in the pleural cavity makes the percussion of the 
clavicle on the affected side much duller. 

Percussion over the sternum is resonant with a pe- 
culiar bony note. The sternum acts as a sounding board 
and is influenced to a slight extent only by the normal 
underlying tissue. When the normal resonance of the 
sternum is diminished and a dull sound is obtained it 
shows that these vibrations are interfered with by in- 
trathoracic conditions that replace the anterior edges of 
the lung, as solid growths in the mediastinum and en- 
larged bronchial glands, fluid accumulations in peri- 
cardium, or aneurysmal dilatation of the aorta. 

The ease with which the bony thorax is thrown into 
vibration varies at different periods of life. 

In the child, on account of the flexibility of the ribs, 
vibrations are easily conveyed to the underlying lung, 
and a clear, well-defined pulmonary resonance is ob- 
tained, scarcely modified by the sound given off by the 
bony thorax. "Percussion in children should therefore 
be light, otherwise diffuse vibrations are set up and reso- 
nance is obtained from a large extent of lung tissue. 

As the bones of the thorax become more rigid, espe- 
cially in old age, the bony sound becomes more marked 
and there is a raising of pitch, so that it is described as 
a boardy or wooden note. 

(3) Influence of the Pleura. — The normal pleura has 
practically no effect on the vibrations produced by per- 
cussion, but pathological changes which canse thickening 
influence them in a marked degree. 



88 



TEE RESPIRATORY SYSTEM. 



On account of the close relation that the pleura bears 
to the ribs a very slight thickening is sufficient to inter- 
fere with the vibrations that are set up by percussion of 
the overlying structures. This is detected not only ir 
the sound elicited, but in a peculiar "hard feeling" im- 



Fig. 27 




1 and 2 show effect of weak percussion over pleurae. 3 and 4 show 
effect of strong percussion over pleurae. 



PERCUSSION. 89 

parted to the fingers. The ordinary springy condition is 
changed to one of increased resistance and varies in de- 
gree accord in"; to the character of the changes in the 
pleura. 

When the thickening is caused by now tissue homo- 
geneous with the pleura, then its influence is slight. If 
a thick layer of plastic exudation covers the surface then 
the dullness will be in direct proportion to its thickness: 

A collection of fluid within the sac renders the note 
flat, the feeling being similar to that noticed when the 
thigh is struck. 

In order to determine whether or not the variation in 
the resonance is due to pleuritic thickening or to changes 
in the pulmonary tissue, the effect of percussion of 
different degrees of force must be used. 

Light percussion will be markedly influenced by 
slight pleuritic thickening, while in very forcible per- 
cussion the vibrations are so strong as not to be inter- 
fered with to any appreciable extent. This is shown in 
Figs. 27 and 28*. 

(4) Influence of the Pulmonary Tissue. — The resonance 
tli at is obtained from the thorax is due to the lung being 
an air-containing organ, and the elements of sound de- 
pend largely upon the condition of the tissues of the 
lung itself and the amount of air contained. 

The walls of the alveoli, on account of their marked 
distension and the tension, are easily thrown into vibra- 
tion, giving a sound with a characteristic quality, low 
pitched, of great intensity and duration — the normal 
pulmonary sound or resonance. 

(a) Change in Tension. — Increase in tension of 
the pulmonary tissue causes an exaggeration of the 
normal resonance. The two conditions in which this 
occurs are in acute compensatory emphysema of the lung 
before the duration of the distension has allowed of 
permanent dilatation, and in children where there is 
marked elasticity of the alveolar walls and relative over- 
distension of the lung. 



90 TEE RESPIRATORY SYSTEM. 

The slight change in the tension of the lung that 
occurs at the end of full inspiration and expiration 
causes a slight variation in the resonance. It is most 
marked at the borders of the lung. 

Decrease in the tension of the pulmonary tissue gives 
a tympanitic quality to the sound. The change in ten- 
sion may involve both lungs and be due to pathological 
changes in the pulmonary tissue decreasing its elas- 
ticity, as in emphysema. 

The tension of the lung is also lowered by marked 
upward displacement of the diaphragm is it occurs in 
increased intra-abdominal pressure from ascites, tumors, 
etc. The tension of the lung is also relaxed by any 
accumulation of fluid in the pleural sacs. In old age 
not only is the pulmonary elasticity diminished with a 
lowering of tension, but the rigidity of the thoracic wall 
causes the percussion note to have a peculiar tympanitic 

quality. 

The changes in tension may be local, as occurs over 
the affected area during the first and third stages of 
croupous pneumonia and in the unaffected portions of 
the lung on the same side during the second stage, due to 
enlargement of affected portion. This is most marked 
when the entire lower lobe is involved. When the 
pleural cavity is sufficiently filled with fluid to allow of 
relaxation of the lung the same condition occurs. The 
peculiar tympanitic resonance over the relaxed portion 
of the lung in the second stage of pneumonia and in 
pleurisy with effusion has been named Skoda's reso- 
nance. 

One of the earliest signs of tubercular infiltration of 
a portion of the lung, especially when it affects the apex, 
is the slight tympanitic quality of the percussion note. 

The influence of diminution in the pulmonary tension 
upon the percussion note of the thorax demands further 
consideration. 

In the normal chest, when the blow is struck upon the 
bonv thorax the negative pressure or suction action of 



PERCUSSION. 91 

the lungs causes a movement inward of the ribs, while atj 
the same time it prevents a corresponding free outward 
rebound. This has the effect of dampening the vibra- 
tions of the bony thorax. The sound obtained is that of 
the pulmonary tissue modified to but a slight extent by 
the peculiar sound of the bony thorax. 

With diminished elasticity of the lung and decrease 
in the negative pressure when the bony thorax is per- 
cussed its movements are not influenced to the same 
degree by the lung and the percussion note contains a 
larger proportion of the bony quality and pitch, while 
at the same time the pitch of the pulmonary resonance 
is lower and the sound obtained is described as slightly 
high pitched, wooden or boardy. 

In percussing the thorax in diseases in which a lower- 
ing of the tension occurs the examiner must exclude the 
bony quality of the sound and heightening of the pitch 
that occurs. 

(b) Change in Amount of Pulmonary Tissue. — 
Increase in the amount of pulmonary tissue in any por- 
tion of the lung, whether or not it diminishes the air- 
containing space, produces a change in resonance. This 
change is described as dullness, and is characterized by 
heightening of the pitch and a peculiar hardening of the 
quality, with diminished intensity and duration. If the 
size of the air-containing spaces be decreased at the same 
time that the solid structures of the lung are increased 
the diminution of resonance would be in direct propor- 
tion to the changes. When the tension of the tissue is 
higher than normal the pitch will be markedly raised ; 
while, on the other hand, if there is marked relaxation 
the dullness will be attended with a lowering of the pitch 
and will have a tympanitic quality. 

Increase in the tissue of the lung relative to the air- 
containing spaces occurs with fibrosis where the normal 
structures are increased either as a result of germ infec- 
tion, especially by the tubercle bacilli, or of mechanical 
irritation as in the conditions classified under pneumo- 
coniosis. 



92 TEE RESPIRATORY SYSTEM. 

(c) Changes in the Air-Containing Spaces. — ■ 
Increase in the size of the air-containing spaces and the 
amount of air contained in the lung causes a marked 
augmentation of the resonance produced by percussion 
and the quality of the sound will depend upon the 
physical condition of the pulmonary tissue. With the 
enlargement of the air spaces if the tension of the pul- 
monary tissue is increased, as occurs in compensatory 
emphysema and in acute asthma, the pitch is slightly 
raised and the sound is abnormally clear. When the 
pulmonary tissue is relaxed, as in large lung and in the 
senile form of emphysema, the pitch is lowered and of a 
tympanitic character, giving the typical emphysematous 
or "band-box" percussion note. 

When destruction of a portion of the lung tissue 
occurs, forming large air-containing spaces or cavities, 
the percussion sound will depend upon their situation, 
size, form, condition of the walls and the surrounding 
tissue, and whether or not it is open or closed and the 
amount of fluid contained. 

Cavities lying close to the surface, especially at the 
apex, and opening more or less directly into a medium- 
sized bronchus, give the most marked sound and those 
the size of a walnut can be detected by percussion. When 
situated deeper in the lung and surrounded by fairly 
normal lung tissue only a faint tympanitic quality may 
be noted. When covered by thickened lung tissue or 
by thickened pleura the sound becomes dull and at the 
same time slightly tympanitic. This has been variously 
described as boardy tympanitic, dull tympanitic, etc. 
The influence of the overlying tissue may be so great 
that no cavity sound can be obtained. (Fig. 29.) 

When the walls of the cavity are rigid, the pitch of 
the sound changes. In those with lax walls the sound is 
described as cavernous. The quality is tympanitic; the 
pitch is low, with intensity and duration proportionate. 
In those with tense, rigid walls it is described as 
amphoric, with a more marked resonance and higher 



PERCUSSIOX. 93 

pitch. These variations in sound are comparative; the 
cavernous merges into the amphoric, and numerous sub- 
divisions have been made, as caverno-amphoric, etc. 

When the bronchus leading to a cavity is closed, the 

tympanitic sound is less marked, and the sound is duller 
and high pitched. 

Certain peculiar changes have been delected over 

cavities : 

Wintrich's Change of Sound, or Forcible 
Pitch. — In cavities opening into a large bronchus, and 
situated near the surface of the lung, a change of pitch 
is' noted when percussion is made with the mouth open 
or shut. When the mouth is wide open, it is high 
pitched, and more tympanitic than when the mouth is 
closed. Frequently cavities that give no distinguishing 
sound when the mouth is closed are easily detected 
when the mouth is open. 

Gerhardt's Change of Sound. — At times the 
pitch and intensity of the tympanitic sound over a 
cavity changes with the posture of the patient. Various 
explanations have been given of this phenomenon, but 
it is probably due to alterations in size and form of the 
cavity, its relation to the chest wall and the connecting 
bronchus. The si an is not often detected, but when 
present is diagnostic of a cavity. 

Friedrich's Eespiratory Change of Sound. — 
This is noted when percussion is made during forcible 
inspiration and expiration, and is dependent upon the 
changes that occur in the size of the cavity and the 
tension of its walls. 

The Cracked-Pot Sofxd. — This is a peculiar 
''clinking'' sound heard when, during expiration with the 
mouth open, forcible percussion is made over a cavity 
connectine; directlv with bronchus and is most easily 
obtained when the cavity is situated in the upper portion 
of the lung and the chest walls are flexible. This sound 
can be imitated bv looselv clasping the hands with 
palmar surfaces slightly touching and forcibly striking 



94 



THE RESPIRATORY SYSTEM. 



the back of one hand on the knee, thus' forcing the air 
through the narrow chink formed. This sound while 
most frequently found in cavity formation may be pro- 

Fig. 28. 



Normal 



Dulness 



Flatness 




Impaired 



Normal 



Variation in sound caused by changes in pulmonary tissue as elicited 

by the force of percussion blow. 

duced by forcible percussion in the normal lung when 
the thorns is very elastic, as in children. 



PERCUSSION. 



95 



Decrease in Size. — As the pulmonary resonance is 
due to the air contained in the lung, diminution in the 
amount will be attended by a corresponding decrease of 



Fig. 29. 




Oeep Seated Consolidation 

masked by V 

Empliysematous Lung 



Localized Emphysema 
Compensatory 
to 
Consolidation 
(Dulness) 



Dulness with 
Tympanitic quality 



resonance. If the displacement of the air is complete 
then percussion of that portion of the lung will be sim- 



96 



TEE RESPIRATORY SYSTEM. 



ilar to that obtained over any solid, airless tissue, as the 
thigh or liver, and the sound will be designated as flat, 

It is necessary that a clear distinction be made be- 
tween dullness and flatness. As long as any resonance 
can be detected, the term dullness must be used with 
some qualifying word denoting its degree. Flatness 
means that the sound is absolutely devoid of any reso- 
nance. 

Fig. 30. 




Absolute and relative heart and liver dullness and flatness. 



It is rare for pulmonary consolidation to give a per- 
fectly flat note, as there is usually enough air in the 
bronchi of the affected portion to give slight resonance. 

Liquid effusions and solid growths in the pleura] 
cavity are frequently large enough to give a perfectly 
flat sound. 

The percussion note obtained when the lung has been 
rendered more or less airless or solid depends upon the 



PERCUSSION. 97 

seat of the consolidation. If the consolidated area is 
close to the surface, immediately underneath the pleura, 
its influence upon the resonance would be marked and 
it can be best detected by light rather than by heavy 
percussion. If it is situated deeper in the lung and 
separated from' the pleura and bony thorax by a zone 
of air-containing lung, then, in direct proportion to its 
depth, will it influence the resonance obtained and more 
forcible percussion is needed. This can be best under- 
stood by referring to Figs. 28 and 29. 

(5) Influence of Heart and Liver. — The resonance 
of the lung is impaired by the solid structures (heart 
and liver) that are covered to a greater or less extent 
by pulmonary tissue. The extent and degree of the 
dullness will depend upon the size and mobility of the 
lung on the one hand and that of the solid organs on the 
other. 

The dullness that is detected over these organs, which 
gradually increases in degree until it merges into thq 
perfectly flat sound of the organ itself, is known as rela- 
tive cardiac and liver dullness. The influence of these 
organs upon the resonance and force of the blow neces- 
sary to elicit this relative dullness is indicated by Figs. 
30 and 31. 

The normal boundaries of these areas and the diag- 
nostic sieiiificance of changes in extent are discussed 
under "Percussion," Parts III and IV. 

INDIVIDUAL AND REGIONAL VARIATIONS OF 
PERCUSSION SOUND. 

From what has been said about influence of the dif- 
ferent structures upon the percussion note, it is readily 
appreciated that no standard can be set. Each patient 
will have an individual variation within the range of 
normal, as the soft parts are thick or thin, the bony 
thorax flexible or rigid, the lungs large or small, with 
high or low tension, and, in addition, the sound will 
vary according to the portion of the thorax percussed, 

7 



98 THE RESPIRATORY SYSTEM. 

As the value of percussion lies in the comparison of 
the note obtained over corresponding spots on the two 
sides it is necessary to keep in mind the normal varia- 
tions that occur over these spots. 

The percussion note over the right lung, from the 
apex to the second interspace in the axillary line, is 
slightly higher in pitch and duller than on the left side. 
This is due to the bronchi on the right side being rela- 
tively larger and nearer the surface. The change in 
percussion corresponds to the increase in vocal fremitus 
over the same area. This does not hold true for infants 
and young children up to seven or eight years of age, 
where the percussion in the inner third of the infra- 
clavicular space on the left side is duller than on the 
right side. This is because the anterior border of the 
lung in infants and young children does not extend as 
far "toward the median line as in adults, and the great 
vessels and upper part of the heart are in more intimate 
relation to the chest wall. 

The percussion note on the right side from the fourth 
interspace downward is modified by the relative liver 
dullness, while on the left side, beginning at the third 
interspace, close to the sternum, and corresponding to 
the site of the heart, the cardiac relative dullness and 
flatness are present. These variations are noted in 
Fig. 30. 

PERCUSSION OUTLINE OF LUNG. 

Percussion gives valuable information concerning 
the size and mobility of the lung, and no examina- 
tion is complete unless the percussion outline of the 
borders of the lung during inspiration and expira- 
tion is determined/ The only boundaries or borders 
that can be definitely mapped out by percussion are the 
superior or apex of the lung, the inferior or bases, and 
that portion of the anterior that is not covered by the 
sternum and overlies the heart. Above the clavicle the 
apices of the lung rise from one to one and one-half 



PERI JUXSION. 



99 



inches. In exceptional cases they may reach as high as 
two inches. The apex is free and unsupported by bone-, 
but below is bound down by the rigid first rib. Tho 
right apex rises somewhat higher than the left (one-half 
inch), but this is not demonstrable by percussion. It is 
impossible by percussion to map out with absolute 
accuracy the upper border. The most that can be deter- 

Fig. 31. 




Relation of lungs, pleura, heart and liver to bony thorax. 



mined is the decree of resonance above the clavicle and 
the changes that occur with inspiration and expiration. 
On account of the difference in the thickness of the over- 
lying tissue the force of the percussion blow must vary. 
In that portion that lies above the clavicle and is bound 
towards the median line by the inner side of the sterno- 
mastoid muscle and later ally by the inner border of the 



100 



TEE RESPIRATORY SYSTEM. 



trapezius, the percussion blow must be very light. It 
will be noted that the resonance diminishes from the 
clavicle upwards until about two fingers' breadth above 
the clavicle the note becomes dull. Over the trapezius, 
from the inner side of the trapezius to the vertical line 
along the spine and which corresponds to the posterior 
portion of the apex of the lung, the percussion Wow must 

Fig. 32. 




Percussion outline of the lung (posterior). 



be fairly forcible, and the resonance gradually dimin- 
ishes until it is lost at a point which corresponds to the 
level of the spine of the first dorsal vertebra. The uppei* 
limit of resonance varies in health. After forcible ex- 
piration it is found lower and the amount of resonance 
above the clavicle is diminished. If a deep inspiration 
be taken and the breath held, and the muscles holding 



PERCUSSION. 101 

the bony thorax are allowed to relax, there will be an 
extension of resonance upwards due to inflation of the 
apex. The actual carrying upwards of the line of the 
apex is not as noticeable as the fact that that portion 
above the clavicle becomes more resonant. If per- 
cussion is made over the anterior portion of the 
apex at the end of forced inspiration and while the 
patient by the contraction of the accessory muscles of 
inspiration is holding the thorax in an elevated position, 
very little information can be obtained — in fact, the 
area of percussion dullness above the elevated clavicle 
is less than in quiet breathing. If the patient, after 
taking a full inspiration, is directed to hold his breath 
and at the same time allow the muscles of the neck and 
thorax to relax, there will be a more marked inflation 
of the apex of the lung and its distensibility can be more 
readily appreciated. In emphysema the resonance of 
the apex is higher than normal during expiration, but 
there is not a corresponding increase during inspiration 
and the note has a tympanitic quality with but slight 
change at the end of full inspiration. In tubercular in- 
filtration of the apex and in pleuritic thickening the 
increase of resonance is not detected at the end of full 
inspiration when the breath is held. Over the posterior 
portion of the apex the most important point to deter- 
mine is the height which the resonance reaches audits 
relation to the spine of the first dorsal vertebra, for- 
mally, the line of resonance from the inner margin of 
the trapezius curves downwards to the end of the first 
dorsal spine. In the percussion of the posterior portion 
of the apex the relation of the upper limit on both sides 
is most important They should correspond. When 
one is lower than the other it indicates some abnormal- 
itv and demands special investigation. The early indi- 
cations of disease at the apex of the lung are the 
failure of the upper line of resonance on one or the 
other side to ascend during deep inspiration with a 
corresponding increase of resonance ; second, a lowering 



102 TEE RESPIRATORY SYSTEM. 

of the upper line of resonance in all or in part as com- 
pared with that on the opposite side (a slight allowance 
is to be made for the left side, as it normally does not 
rise quite as high as the right) ; third, indistinct defini- 
tion of the upper or outer lines of resonance, i. e., the 
resonant and dull areas merge more or less into each 
other ; fourth, the inward displacement of the outer line 
of resonance. 

To determine the position and mobility of the lower 
portion of the lung is most important. The lower line of 
resonance should be determined on quiet breathing. 
The patient should then be instructed to take a full 
breath and hold it and the lowered level of the resonance 
again determined. After forced expiration the upper 
limit of the border should again be determined. In this 
way it is possible to determine the mobility of the lung. 
The mobility of the lung is diminished by, first, loss 
of muscular power; second, rigidity or immobility of 
the bony thorax; third, thickening or adhesions of the 
pleuritic sac obliterating the complemental spaces; 
fourth, changes in the lung which interfere with it3 
elasticity or distensibility. It is not necessary that the 
changes in the lung which interfere with the extensibil- 
ity of the lower border of resonance should be limited 
to the base. Fluoroscopic examinations have shown that 
when there is a slight infiltration of the apex there is a 
corresponding loss of motion of the diaphragm on the 
affected side. On the right side the relation of the lung 
to the liver renders mapping out of the lower border of 
pulmonary resonance easy. On the left side, on account 
of the relation of the lung to the resonant abdominal 
organs, the lower level can only be determined over that 
portion of the axillary line where the lung is in relation 
to the spleen. (Figs. 31 and 32.) 

AUSCULTATORY PERCUSSION ( Stethoscopic Percussion) 

In this method the chest piece of the stethoscope is 
placed upon the chest over the organ that is under exam- 



PERCUSSION. 



103 



ination; mediate and immediate percussion is made 
from a distance toward the point where the stethoscope 
rests, and the variations in the sound are noted. \\ hen 
the percussion is made directly oyer the organ a 
marked increase in the intensity of the vibrations is 
both heard and felt. 

Fig. 33. 




Within certain limitations it is a valuable method of 
examination, allowing of a differentiation between com 
ditions giving the same sound, as between the flatness ol 
the heart and liver where the two organs are contiguous ; 
between right-side pleurisy with effusion, pulmonary 
consolidation and liver flatness. 



104 TBE RESPIRATORY SYSTEM. 

In order to be of use, the chest piece of the stetho- 
scope should be small and rest wholly over the organ* 
under examination. A special part to replace the ordi- 
nary chest piece should be used so as to allow of its 
being placed between the ribs, thus avoiding the vibra- 
tions readily conveyed by the bony thorax. The per- 
cussion should be light and, as the value is comparative, 
the points percussed should be equally distant from the 
tip of the stethoscope. 

Another method which I have found very sensitive 
and which avoids the vibrations of the bony thorax is 
to listen to the percussion note with the chest piece of 
the stethoscope not touching the surface but held just 
above and close to the point of percussion. In mapping 
out the relative dullness of the heart and liver, it is 
more definite than when chest piece rests on the bony 
thorax. (Fig. 33.) 

A modification of auscultation percussion is the use 
of a tuning fork to set up vibration in the chest wall 
instead of finger percussion. Tuning fork A (435 
vibrations per minute) or C is used. The bell of 
the stethoscope is placed over the organ to be outlined 
and the vibrating tuning fork is placed outside the 
limits of the organ and moved toward the stethoscope 
until a change in the quality of the tone is noted. By 
approaching the boundaries of the organ from different 
direction^ a very accurate outline may be obtained. 
When solid organs are in contact their borders can be 
determined. A considerable amount of practice is 
needed to j get the best results. 



CHAPTER V. 

AUSCULTATION. 

Auscultation of the lungs is the act of listening at 
the surface for the sounds made within the thorax dur- 
ing the act of breathing and may be performed in two 
ways: Immediate, in which the ear is placed directly 
upon the chest, or which is protected by a thin covering. 
Mediate, in which one of the different forms of stetho- 
scope is used. 

Each method has its advocates and both are useful. 
The advantages of immediate auscultation are that (a) 
there are no modifications of sound occurring through 
the use of instruments; (b) the ear appreciates better 
the slio-ht changes in the normal elements of the sound; 
(c) the ear notes the movements of the thorax which 
occur at the time the sound is heard; (d) there is less 
exposure of the surface. 

The advantages of the use of the stethoscope, or 
mediate auscultation, are: (a) It is easier to examine 
certain portions of the chest more or less inaccessible to 
the ear, as the supraclavicular fossa; (b) it limits the 
sphere of examination to the small area covered by the 
chest piece of the stethoscope; (c) delicacy often dic- 
tates its use over certain portions of the body, as the 
breasts; (d) the examiner avoids infection and contami- 
nation by parasites. 

The disadvantages are that certain elements of sound 
are modified or distorted bv the resonance of the instru- 
ment used and many extraneous sounds are also intro- 
duced, as rubbing or scratching frictions sounds made 
by the rubbing of the stethoscope on the surface, and 
muscle sounds or creakings are intensified. Children 



106 THE RESPIRATORY SYSTEM. 

are often frightened by use of an instrument. Where 
a person is very thin, it is impossible to have the stetho- 
scope fit closely to the surface and so to exclude the 
sounds present in the room. 

Students should become thoroughly familiar with 
the sounds obtained by the direct method and should 
use the indirect for certain special purposes only. 

To auscultate satisfactorily attention should be given 
to the position of the patient. Both sides of the chest 
should have opportunity to move with equal free- 
dom. The patient should breathe naturally and care 1 
should be taken that inspiration and expiration are not 
noisy. It is impossible for many persons to breathe 
naturally when their attention is called to the act. 
Usually the inspiration is taken quickly and forcibly; 
the breath is held for an appreciable time, and then 
either forced out rapidly or allowed to escape so slowly 
that no sound is heard. In nervous patients fairly nat- 
ural breathing may be obtained after coughing or by 
having the patient first talk for a certain time, All con-> 
stricting clothing, as stays, etc., should be removed, so 
that the chest may move as freely as possible. As 
the value of auscultation is comparative, symmetrical 
points on the two sides should be examined and the 
differences noted. 

PHYSIOLOGY OF NORMAL BREATH SOUNDS. 

It is necessary to have a clear understanding of the 
manner in which the normal respiratory murmurs, or 
breath sounds, are produced in order to appreciate and 
correctly interpret the variations that are heard over the 
different portions of the lung in health and the altera- 
tions that occur in disease. 

As the name implies, the breath sounds depend upon 
the respiratory movement, and necessarily occur only 
during inspiration and expiration. The modifications 
of these sounds heard over the different portions of the 
chest may be divided into two groups : 



AUSCULTATION. 10 7 

(A) Those which depend upon the variations in the 
normal sounds. These variations are limited to (a) 
quality or character, (&) intensity, (c) pitch, (d) dura- 
tion, (e) rhythm, (/) the relative length of expiration 
and inspiration to each other. 

(B) To the production of new or adventitious 
sounds or rides, which may be dry or moist, friction, 
etc. See page 123. 

During inspiration enlargement of the thoracic 
cavity occurs in all directions, causing (a) movement 
of air in the respiratory tract; (&) change in the tension 
of the tissues forming the walls of the bronchi, bron- 
chioles and alveoli. 

In quiet breathing 30 cubic inches of tidal air are 
drawn into the respiratory tract during inspiration and 
forced out during expiration, and as the estimated 
capacity of the larynx, trachea and bronchi is 10 cubic 
inches, and that of the alveoli after quiet expiration is 
150 cubic inches, it, is evident that the tidal air is car- 
ried even into the alveoli and that there is aerial move- 
ment throughout the entire respiratory tract. Passing 
to and fro through the glottis the tidal air is thrown 
into vibrations that are intense enough to be audible. 

Laryngeal Breath Sounds. — The sound produced at the 
glottis is known as the laryngeal breath sound and has 
the following characteristics: It is heard with both 
inspiration and expiration, but with a distinct break or 
pause between them, as the inspiratory sound is not 
audible during the latter part of the act. 

The sounds produced during inspiration and expira- 
tion are nearly equal in length, that of expiration being 
slightly longer. The sound is harsh and blowing, the 
quality being tubular; the pitch is high, that of expira- 
tion being harsher and higher pitched than that of 
inspiration. 

When the mouth is closed and the breathing is 
through the nose the sound produced is more intense, 
harsher and higher pitched as the vibrations made at 



108 THE RESPIRATORY SYSTEM. 

the glottis are reinforced by those produced in the 
pharynx. The laryngeal sound may be imitated by 
placing the tongue in the position to pronounce "h" or 
a ch" and breathing deeply and regularly. 

The intensity and character of the laryngeal sounds 
depend (a) upon the force and rapidity with which the 
tidal air rushes through the glottis; (b) the size of the 
glottis; (c) the position of the vocal cords; (d) the con- 
dition of the tissues of the larynx. Thus the sounds 
vary to a certain extent in each individual. As the 
vibrations made at the glottis are the basis of ail sounds 
normally heard over the lung the laryngeal breath 
sounds serve as a standard in each case by which an 
estimate can be formed of what should be the normal 
intensity of the respiratory sounds heard over the other 
portions of the chest. 

The vibrations made at the glottis are conducted 
through the respiratory tract simultaneously by two 
channels: (1) aerial, i. e., vibrations of columns of 
air contained in the bronchi, bronchioles and alveoli; 
(2) the tissues of the walls of the bronchi, bronchioles 
and alveoli. 

Aerial Conduction. — The laryngeal sound is conducted 
by the aerial vibrations through the trachea to its bifur- 
cation into the primary bronchi almost unchanged 
except for a slight toning down of the harshness. The 
laryngeal or tracheal sound represents the highest type 
of tubular or bronchial breathing and is normally heard 
over the larynx and trachea; at times over the upper 
portion of the sternum in front and over the vertebral 
column as far as the fifth dorsal vertebra behind. It 
is heard over other regions of the chest only when patho- 
logical changes have occurred in the respiratory tract 
that permit its conduction from its normal site to other 
areas. 

At the bifurcation of the trachea the column of mov- 
ing and vibrating air is divided into two uneven parts, 
the larger passing to the right bronchus, the smaller to 



AUSCULTATION. 109 

the left. With this division certain changes occur 
which influence the aerial vibrations that have been 
carried down from above. 

(1) The united capacity of the two bronchi being 
greater than that of the trachea the force of the current 

of tidal air is less. 

(2) Eeflection or reverberation of the laryngeal 
vibrations which causes confusion of the sound. 

(3) The impinging of the column of air on the angle 
of bifurcation adds new vibrations and a new quality 
of sound to that received from above. 

Tissue Conduction. — The vibrations transmitted 
through the walls of the trachea and bronchi convey the 
laryngeal sound unchanged in quality and but slightly 

weakened. 

The effect of these two series of vibrations is to so 
modify the sound in the primary bronchi that it can be 
distinguished as a type, i. e., bronchial breathing. 

Bronchial breathing differs from the laryngeal sound 
as follows: The tubular quality is slightly diminished, 
and is less sharp, the change being most marked on in- 
spiration. The pitch is not as high and there is a cor- 
responding loss in intensity and harshness. Inspira- 
tion and expiration are nearly equal in duration, ex- 
piration alone being slightly shortened, and the pause, 
while present, is not so marked. 

As the tidal air descends along the bronchial tract at 
each division of the column changes occur similar to 
those at the bifurcation of the trachea. 

The Modifications of the Aerial, Vibrations 
that occur in the different divisions of the bronchi are 
as follows: (1) The increased capacity of the branch- 
ing tubes (a) reduces the force of the current in the 
tidal air and (&) causes diffusion of the vibration. 
These two factors lead to a loss of intensity in tho 
sound produced. 

(2) The refraction or reverberation occurring in the 
bronchi causes the tubular laryngeal sound to become 



110 THE RESPIRATORY SYSTEM. 

confused in character, the harsher tones being espe- 
cially modified, while the more musical elements per- 
sist. This makes the pitch of the sound lower than 
that which is heard in the large bronchi and larynx. 

Obliteration or change in the harsher qualities has 
been variously explained, but the mere fact of their 
loudness or harshness causes their reverberation to 
occur more easily and therefore the primary vibrations 
are interfered with by the secondary vibrations of re- 
verberation. 

(3) At each bifurcation of the bronchi the moving 
column of tidal air has sufficient force to set up new 
vibrations, which, being added to those received from 
above, modify the quality of the sounds, and although 
the sound remains tubular, it has a softer blowing 
character. 

The Modifications of Vibrations through Tis- 
sue Conduction. — The walls of the large and medium- 
sized and cartilaginous bronchi are good conductors of 
vibration. The change that occurs as the vibrations are 
carried through the tissues of the different branches of 
the bronchial tree is chieflv loss of intensitv, but the 
bronchial character persists. On account of the rigidity 
of the bronchi tissue vibrations are influenced but 
slightly by the aerial vibrations within them. 

As a result of these two classes of vibrations, aerial 
and tissue, the sounds heard over all portions of the 
bronchial tract will be more or less characteristic. The 
pause between the inspiratory and expiratory sounds in 
the larynx is well marked. This pause becomes less 
and less marked the farther down the respiratory tract 
the examination is made. This is due to the more 
continuous movement of air during inspiration and 
expiration in the lower divisions of the bronchi. Above 
there is merely the tidal air going in and out; below 
there is the more continuous movement of not only the 
tidal air, but also the columns of residual air. During 
the latter portion of inspiration the air passes through 



AUSCULTATION. Ill 

the glottis without setting up audible vibrations, while 
on account of the position of the vocal cords during 
expiration audible vibrations are produced throughout 
the entire act. Lower down in the bronchi the added 
vibrations cause a continuous sound, increasing in in- 
tensity, to be made throughout inspiration, while in 
expiration the current becomes progressively feebler. ^ 

In the larynx and large bronchi the tubular quality 
of the sound is equal during inspiration and expiration. 
Over each successive lower division of the bronchi the 
inspiratory sounds lose their pure bronchial character, 
while the expiratory sound retains it to a greater degree. 
This difference in the amount of tubular element is due 
to the fact that in inspiration new vibrations are added 
at each division of the bronchi, which modify the tubu- 
lar quality. During expiration, on the other hand, no 
new sounds are added. 

If it were possible to apply the ear or the stethoscope 
to the different subdivisions of the bronchial tree, each 
would give its own peculiar type, having a characteristic 
quality, pitch, intensity and duration. ( Fig. 34.) 

Certain pathological conditions allow these varying 
degrees of bronchial breathing to be heard at the sur- 
face, and according to the character of the sound heard 
the nature and extent of the anatomical changes in the 
lung are determined. 

Changes in the Bronchioles and Alveoli. — 
From what has already been said of conduction of the 
glottic vibrations by the air contained in the trachea and 
bronchi and by the walls of the tubes, and the modifica- 
tions that occur in the sound in different portions of the 
bronchial tract, it is easy to understand that still greater 
modifications will take place in the bronchioles and 
alveoli. As long as the divisions of the bronchial tubes 
contain cartilage and muscular tissue the vibrations 
transmitted through the homogeneous tissue preserve in 
a large measure the tubular quality of the laryngeal 
sound and are not easily modified by the aerial vibra- 
tions, 



112 TEE RESPIRATORY SYSTEM. 

''Below the diameter of 1-24 inch. (1 mm.) the bron- 
chial tubes have neither cartilages, niucous glands nor 
any continuous muscular coat : circular and longitudinal 
elastic fibres replace the muscular coat." (Powell.) 

This change in the structure of the bronchi has a 
marked influence on the condition onward towards the 
surface of the larvngeal sounds, which has been a 
marked a feature of the vibrations transmitted by the 
tissues. As the structure of the bronchioles and alveoli 
becomes less and less homogeneous with that of the 
larger bronchi the vibrations received from above are 
not conveved so easilv. The loss of the tissue vibration 
causes a dampening of the tubular or bronchial quality 
of the sound. As the structures of the bronchial tubes 
and alveoli becomes more membranous and tense they 
are influenced to a greater degree bv the aerial vibra- 
tions. 

The rapid breaking up of the smaller bronchi into 
bronchioles causes a still more marked change in the 
aerial vibrations received from above. They are dif- 
fused, reflected again and again, the sound is confused, 
the harsh tubular and blowing character is lost, the 
softer, more continuous and rustling (musical) quality 
alone remaining. 

There has been much discussion whether the move- 
ment of the tidal air in the bronchioles and its passage 
into the alveoli is sufficient to produce audible vibra- 
tions and whether the sound heard at the surface of the 
lung during inspiration is due entirely to the vibrations 
made at the glottis, changed bv transmission through the 
lung, or is in part composed of vibrations made at the 
junction of the bronchioles with their infundibuli. 
S<une claim that the sound heard at the surface during 
inspiration is made in the alveoli. 

After quiet expiration the capacity of the alveoli is 
estimated at 150 cubic inches : the amount of tidal 
air in quiet breathing is 30 cnbic inches, which in forced 
inspiration and expiration may reach 200 cubic inche- 



AUSCULTATION. 113 

in man and 150 cubic inches in the female. There is 
no question but that it is possible for the tidal air to pass 
from the narrow bronchioles into their relatively wide 
infundibuli with sufficient force to produce vibrations 
which, if not audible in themselves, would intensify in 
some respects and modify in others the vibrations which 
had their origin at the glottis. 

The aerial vibrations, and especially those in the 
alveoli, play an important part in the production of 
the inspiratory sound heard at the surface. They 
explain why the vesicular element is present to a greater 
or less extent as long as tidal air reaches the alveoli 
even though changes in the stroma of the lung may 
allow bronchial sound to be heard through tissue con- 
duction, and why inspiration does not have as tubular a 
quality as expiration. In inspiration through the 
enlargement of the thoracic cavity the tissues of the 
alveoli and bronchioles are rendered more tense, have 
greater power of conduction, and are more easily thrown 
into vibrations, so that there is a corresponding increase 
in the intensity of the sound up to the end of the act. 

Normal Respiratory Murmur. 

Over the surface of the lung the sounds of inspiration 
and expiration occur at regular intervals. 

The breath sounds (the respiratory murmur) have 
the following characteristics or elements during inspira- 
tion: The quality is variously described as breezy, 
rustling, sighing, slisditlv shuniimr or vesicular, corre- 
spending to the sound produced by regular and natural 
breathing when the lips are placed in a position to pro- 
nounce "F" or "V." The pitch is low; the intensity 
increases to the end, and is heard throughout the act 
(duration). The rhythm is regular. 

All these elements of the respiratory murmur will 
vary normally within wide limits in different individ- 
uals, but will always have a definite relation to the 

8 



114 THE RESPIRATORY SYSTEM. 

intensity of the sounds heard over the larynx and 
trachea, as has already been noted. 

The expiratory portion of the respiratory murmur 
immediately follows that of inspiration, and differs in 
the following respects: The quality is harsher, the 
breezy vesicular element has a slight blowing sound 
added, the pitch is higher, 1 the intensity is less, being 
loudest at the beginning and rapidly fading out so that 
its duration is only one-half to one-third that of inspira- 
tion. 

It is necessary to explain why these modifications 
occur in expiration in order to understand the occur- 
rence of pathological changes. 

It has already been noted that inspiration is a mus- 
cular act which continues until the thorax is fully 
expanded. The laryngeal sound is made at the glottis, 
and is conducted downwards by (1) the current of tidal 
air which is towards the surface of the chest, and (2) 
by the tissues in the bronchi, bronchioles and alveoli, the 
tension of which increases to the end of inspiration. In 
addition to the vibrations made at the glottis, other 
vibrations are added at different parts of the tract and 
especially at the opening of the bronchioles into their 
infundibuli. All of these factors cause the inspiratory 
part of the murmur to have its peculiar quality and 
pitch, to increase in intensity to the end, and to be heard 
throughout the act. 

Expiration, on the other hand, is normally a passive 
act which depends upon the elasticity of the thorax and 
the pulmonary tissue and the contraction of the muscle 
fibres present in the bronchi. These forces are greatest 
at the beginning of expiration. The sound in the larynx 
is made at the level of the vocal cords and the direction 
of the tidal air is upwards and away from the surface of 
the chest. The direction of the expiratory current of 
air interferes with aerial conduction of the sound 
downwards. As the tidal air is forced out of the alveoli 

iMany authors state that the pitch of expiration is lower than 
that of inspiration. 



AUSCULTATION. 115 

into the tubes no new vibrations are made in the bron- 
chioles or tubes. 

The sound that is heard at the surface in expiration 
is chiefly that conveyed by the tissues of the respiratory 

tract, so that the quality lacks the vesicular element and 
is somewhat blowing and hard, and its pitch is higher 
than inspiratory sound. As the tidal air i- forced out 
of the lung the tension becomes less and loses the power 

to conduct, so that the intensity, most marked at the 
beginning, rapidly diminishes and the sound is heard 
only during a short part of the time or may be entirely 
wanting, especially where the expiratory laryngeal 
sound is naturally very soft or the expiratory force 
weak. 

The fact that during expiration the vibrations are 
chiefly conducted by the tissues explains the tendency 
of the blowing or bronchial element to be so much more 
pronounced during this portion of the murmur. 

Regional Variations of the Bbeath Sounds. — 
The breath sounds vary in intensity, duration, quality, 
pitch and in the relative lengths of the sounds heard 
during inspiration and expiration over different por- 
tions of the Inner. 

It is necessarv to have a thorough knowledge of the 
normal variations in order to recognize the alterations 
that occur in morbid conditions, because a tvpe of 
breathing that is normal for one region would be patho- 
logical if heard in another. 

It has already been shown that over the larynx, 
trachea and primary bronchi the tubular sound is heard 
unmodified, and constitutes the laryngeal, tracheal and 
bronchial types of breathing. 

Over the interscapular space opposite the spine of the 
scapula the sound is neither pure bronchial nor entirely 
vesicular in quality and pitch, but is of an intermediate 
character. The tubular sound is modified so that inspi- 
ration has a soft, blowing, but somewhat bronchial char- 
acter, and the pitch is not as hidi as over the trachea. 



116 THE RESPIRATORY SYSTEM. 

The expiratory sound is separated from the inspiratory 
by a shorter pause, and corresponds to the inspiration 
sound in quality and pitch, but its duration is not as 
long as over the trachea. The tubular element is more 
marked on right side than the left, on account of the 
relation of the trachea and bronchi to spine and ribs. 

(Fig. 4.) 

Over the front of the chest on the right side at the 
junction of the second rib with its costal cartilage the 
respiratory murmur differs from that heard on the left 
side in the corresponding region. While vesicular in 
character, there is a slight blowing element added, and 
its intensity and pitch are slightly raised. Over the 
right apex of the lung the same difference is present id 
a more limited degree, due to the origin of the bronchus 
supplying the upper lobe of the right lung. 

The reason for the normal regional differences of 
vesicular murmur is the relative nearness of the large 
bronchi to the chest wall, so that, although these are 
covered by lung tissue, the elements of the bronchial 
sound are present in the respiratory murmur in a 
greater degree than elsewhere. (Fig. 3.) 

GRAPHIC RECORDS OF PHYSICAL SIGNS. 

The graphic recording of physical signs by symbols 
and signs has been advocated and many systems have 
been devised. The most practical are those used by 
Wyllie and Sahli and a modification of these two by 
"Musser. For a number of years I have used a modifica- 
tion of the Sahli method. The value of graphic methods 
of recording physical signs is its ease, the saving of time, 
the ability to locate definitely on a diagram of the chest 
variations from the normal and, for the student, the 
training that it gives in noting the changes in intensity, 
duration, pitch and quality. 

Palpation. — Changes can be indicated by 
YR Normal Fremitus. 



H — o 



AUSCULTATION. 117 

FR+ . . . .Increased Fremitus. 

FR. — . ...Diminished Fremitus. 

FE — 0. .Absence of Fremitus. 
Percussion. — Change in percussion is indicated by 
shading of the affected areas, or a circle may be drawn 
around the area and the following abbreviations used : 

D Dullness. 

SD Slight dullness. 

D — F. .Dullness reaching almost to flatness. 

F Flatness. 

IT II vperrcsonanee. 

T Tvmpanv. 

= Normal vesicular murmur or breath sound. 

+1 = Intensity of vesicular murmur (quality or char- 

acter normal) . 

hi°'h I 
= V Pitched = degree indicated by ancle. 

low J 

to = Duration or length of vesicular murmur (quality 

_ + normal ) . 

=Pause between inspiration and expiration. 
= Interrupted or cog-wheel breath sound. 

J =Wavy breath sounds. 

| ? — Indeterminate respiration or vesicular murmur. 

= Slight tubular or bronchial element added. 

£ =Tubular and vesicular elements about equal 

T_| h (broncho-vesicular). 

± =Nearly pure bronchial breathing and very slight 

"-4h- vesicular element. 

* =Pure tubular or bronchial respiration. 

L-fflh 




118 









TflT RESPIRATORY SYSTEM. 
Cavernous. 

: Amphoric. 

: Sonorous 
Sibilant 



rales. 



/\ =Crepitations /?\ =nioist /\ =dry. 



o o o 
O OO 

oco 

• • • 

• • 



: Moist rales — small, medium and large — more liquid 
in character (Klingend) . 

: Moist rales — small, medium and large — ringing in 
character ( Klangloa ) . 



MMMMA = Friction sounds. 

Types of Respiratory Sound. — Various classifications 
have been made of the different types of breath sounds 
heard in health and in disease. 

Some authors use as a basis of their nomenclature the 
diseases of which the sounds are diagnostic ; others 
employ terms descriptive of the pathological changes. 
The one that is most commonly used and also the most 
satisfactory is that which considers the elements of the 
sounds and groups the types according to the change- 
that occur in intensity, rhythm, duration, quality, pitch 
and the relative length of inspiratory to the expiratory 
sound. 

Changes m Intensity. — (1) Increased, Exagger- 
ated, Compensatory, Vicarious, Puerile Breathing. — 
The chief change from the normal is in the intensity of 
the breath sounds. Inspiration has the vesicular ele- 
ment accentuated. Expiration is slightly longer than 
normal, and of a soft, blowing character. It occurs 
whenever the breathing is very deep and active, as in 
forced voluntarv breathing: also in dyspnoea and over 
portions of the lung, which by increased activity are 
compensating for imperfect action in another part. 

Puerile breathing, which is the normal breathing of 



AUSCULTATION. 110 

children under twelve years of age, differs from exag- 
gerated breathing, in that both inspiration and expira- 
tion are abnormally loud and sharp, and expiration is 
nearly as intense and long as inspiration. It is some- 
what' blowing in character, and may have a slight 
bronchial quality. 

(2) Diminished, Feeble Breathing.— The sounds are 
faint, and heard only for a short time, and expiration 
may be inaudible. The diminished intensity may be 
due to shallow breathing, imperfect muscular action 
caused by weakness, pain in the muscles, nerves or 
pleura; rigidity of the bony thorax; thickness of the 
soft parts of the thorax: and thickenings of or exuda- 
tions and effusions into the pleural sac; interference 
with the movement of air through the bronchi; weak- 
glottic sound dependent upon normal or pathological 
conditions of the larynx. 

The breath sounds that occur when the elasticity of 
the lung is impaired, as in emphysema and old age, 
differ from simple diminished breath sounds, in that 
the inspiratory is short' and weak, and the expiratory 
sound is relatively stronger and longer. 

(3) Absent or Suppressed Breathing. — The breath 
sounds are not heard. This is due to changes that 
render conduction to the surface impossible. It is most 
marked in effusions or serum, pus or blood into the 
pleural sacs; in closed pneumo-thorax with pulmonary 
collapse ; over cavities rilled with fluid ; with occluded 
bronchus, and occasionally when there is great thick- 
ness of the chest wall associated with feeble breathing. 

Altekatioxs ix Khythm. — Interrupted, jerky, 
wary, cog-wheel breathing. Instead of the inspiratory 
breath sound being even and continuous, with a gradual 
increase in intensity, it is broken and puffy. The ex- 
piratory sound may also be uneven. 

This may be due to irregular muscular action, as in 
nervous patients and in painful conditions of the thorax 
and pleura, or to interference with the passage of air 



120 THE RESPIRATORY SYSTEM. 

through the bronchi, as occurs in early tubercular infil- 
tration of the apices, "when the air enters different 
lobules at different times." 

Over the heart and large blood-vessels a peculiar, 
jerky, puffing sound may be heard, due to the cardiac 
systole forcing air from the alveoli and bronchioles. 

Alterations in Duration. — The significance of 
change in duration of breath sounds depends upon (a) 
whether the normal relation is preserved between the 
sounds of inspiration and expiration; (&) whether it is 
associated with adventitious sounds, and (c) whether 
there is any alteration in pitch and quality. 

The inspiratory and expiratory sounds, while preserv- 
ing their normal relations, may be lengthened or short- 
ened by all conditions which have been mentioned as 
producing increased or diminished breath sounds. 

Prolonged Expiratory Breath Sound. — This occurs 
under various conditions. 

(1) When the expiratory sound is prolonged, but is 
low pitched and faintly blowing in quality, it depends 
upon diminished elasticity of the lungs, and is asso- 
ciated with decrease in the length of inspiratory sound, 
with a slight pause between inspiration and expiration. 
Loss of elasticity occurs in old age and in emphysema. 
This type of breathing has therefore been designated as 
' ' emphy sem a tons. ' ' 

(2) The expiratory sound may be prolonged, and 
accompanied by moist or dry rales, due to narrowing 
of the tubes by secretion or by spasm of the muscular 
tissue, as occurs in asthma, bronchitis and the early 
stage of pulmonary tuberculosis. 

(3) A prolonged expiratory sound may be associated 
with a higher pitch and a blowing quality, due to 
changes in the lung which increase its power of con- 
ducting to the surface the sound which is normally 
present in the bronchi throughout the entire expiratory 
act. This may be due to increase in or induration of 
the normal structure of the lung, as in the early stages 



AUSCULTATION. 



121 



Fig. 34. 




122 THE RESPIRATORY SYSTEM. 

of tubercular infiltration, interstitial pneumonia or 
fibroid thickening. 

This type of breathing is normally present over the 
apex of the right lung. 

A prolonged expiratory sound, associated with slight 
increase of the tubular quality and heightening of the 
pitch, marks the faintest alteration in the elements of 
the respiratory sounds in the transition from the normal 
vesicular murmur to the different degrees of bronchial 

breathing. 

Alterations m Quality and Pitch. — The changes 
that occur in the quality or character of the breath 
sounds depend upon the addition of the bronchial and 
tubular and decrease of the vesicular elements. The 
extent to which this may occur varies. Based on the 
proportion of the vesicular and bronchial quality 
present, various subdivisions of bronchial breathing 

have been made : 

(1 ) Broncho-vesicular, indeterminate, subtubular,. 
hinted or indistinct bronchial breathing. Sharp breath- 
ing with bronchial quality in expiration; transition 
breathing; rude respiration; harsh breathing. 

As the names indicate, the distinguishing feature oi 
this type is the presence of both vesicular and bronchial 
quality. This depends upon the changes in the lung, 
which" allow the bronchial sound to be heard at the sur- 
face. These changes may be clue to tubercular infiltra- 
tion, croupous pneumonia, or fibroid induration from 
any cause. It is normally present in the interscapular 

region. 

The term "broncho-vesicular 7 ' is by some extended to 
all cases of bronchial breathing which do not have the 
Avell-marked tracheal quality, while others limit it to 
that type where a faint bronchial quality is added to the 
vesicular breathing. 

The terms "rude" and "harsh" have been used by 
some authors to describe certain grades of broncho- 
vesicular breathing, but should be discarded, as they 



AUSCULTATION. 123 

are misleading, having been employed by others as 
synonyms for exaggerated breathing. 

(2) Pure bronchial breathing is characterized by 
absence of the vesicular quality. Both the inspiratory 
and expiratory sound are high pitched and tubular : 
that of expiration the more markedly so. 

(3) High-pitched, blowing, tubular and tracheal 
breath sounds merely have reference to the intensity and 
extent of the bronchial elements. 

(Jf) Cavernous and amphoric breathing are modifi- 
cations of the bronchial type. The former is low 
pitched and hollow; the latter is high pitched and 
metallic. 

(B) ADVENTITIOUS SOUNDS. 

In addition to the breath sounds there may be heard 
over the chest certain abnormal or adventitous sounds, 
which depend entirely upon pathological changes in the 
bronchi, alveoli and pleura. 

Adventitious sounds are divided into three classes: 

Dry Rales, Moist Rales and Friction Sounds. 

(1) Dry Rales, or rhonchi, are musical sounds, pro- 
duced by vibrations set up in those bronchial tubes 
whose lumen has been markedly narrowed bv tumefac- 
tion of mucous membrane, tenacious exudates, contrac- 
tion of the muscular coats or pressure of tumors. These 
changes are of such a nature as to practically convert 
the bronchial tubes into wind instruments. 

These sounds or rales may vary in quality, pitch, in- 
tensity and duration, according to the size of the tubes 
involved. 

They are usually divided into two types, sonorous 
and sibilant. 

Soporous rales are snoring, low-pitched, loud 
sounds, which may be heard during both inspiration and 
expiration, or may be limited to one part only of the 
respiratory act according to the nature of the cause. 



124 



THE RESPIRATORY SYSTEM. 



They may be heard in connection with the vesicular 
murmur, or may entirely obliterate it. 

Stridor is a type of sonorous rale in which the vibra- 



Fm. 35. 







tions are very coarse and the sound produced hoarse and 
low pitched. It occurs in diseases of the larynx, trachea 
and main bronchi. The vibrations producing stridor 



AUSCULTATION. 125 

and sonorous rales may be strong enough to produce 
tactile fremitus, as described in palpation (rlionchi). 

When the narrowing in the trachea and large bronchi 
is not sufficient to produce a musical sound, but is still 
sufficient to increase the tubular quality normally 
present, it will influence the respiratory murmur by 
adding a bronchial element, as will be described later. 

Sibilant rales are whistling, piping, squeaking, 
humming, hissing sounds, which are markedly musical, 
shrill and high pitched. The quality and the pitch will 
depend upon" the size of the tube, the degree of contrac- 
tion, the force of the current of air, the conditions of the 
pulmonary tissue and the conduction of the sound to the 

surface. 

Dry rales are permanent or transients according to 
the nature of the cause. When the narrowing of the 
tube is due to pressure of a tumor or to a growth within 
the bronchus, the rales will be permanent. When, on 
the other hand, the sound is caused by secretions in the 
tubes or spasm of the muscular fibers, they are variable 
and inconstant, disappearing from one spot and appear- 
ing in another. 

They also change in character. At one time they 
may be hissing, shrill or whistling, and again sonorous, 
as tubes of a different size are involved. Coughing, 
deep inspiration or the inhalation of chloroform or ether 
will modify those of a transient nature, according to 

the cause. 

While usually there is little difficulty in determining 
what rales belong to the dry type, in the finer, less 
musical sibilant ones it is often a matter of opinion 
whether they are to be classified as dry or moist. 

(2) Small, Medium and Large Moist Rales. — ]\Ioist 
eales, as the name indicates, are due to the vibrations 
produced by the movement of air through fluid (mucus, 
serum, blood or pus) in the air-containing spaces of the 
lung. 



126 THE RESPIRATORY SYSTEM. 

Certain characteristics of the rales depend upon the 
nature of the fluid. When it is thin and watery, the 
rales will have a moist, bubbling sound; when it is 
thick, in addition to the moist sound there will be an 
element of sharpness or stickiness, as the bubbles burst 
with an explosive noise. 

The quality and pitch of moist rales are modified by 
the condition of the surrounding lung. When the lung 
is normal, the sound of the rale loses its sharpness in 
transmission, the moist character only remaining. But 
in consolidated areas the rale has a certain ringing 
character, due to the supposed resonating effect of the 
consolidated structures and their increased conducting 
power. 

The variations that occur in the characters of moist 
rales have led writers and teachers to adopt various 
classifications and to designate their subdivisions by 
names which they considered more or less descriptive 
of the sound, or of the pathological condition that ren- 
dered their occurrence possible. 

Unfortunately, different authors do not use the same 
descriptive terms in the same sense, so the "crepitant" 
rale includes not only the finest crackling sound, but 
also those of larger size, which are by others classified 
as "subcrepitant," or "small mucus." 

This want of agreement in classification and nomen- 
clature has led to great confusion, and it is particularly 
perplexing to the student, as it conveys the impression 
that there is a diversity of opinion as to the diagnostic 
significance of these adventitious sounds. 

It is almost hopeless to arrange a classification that 
will include all the terms used. 

Fortunately the tendency is more and more to avoid 
a specific descriptive term and to describe the sound in 
terms of quality, pitch, duration and intensity. 

Crepitations, or "Crepitant Kales/' — These are 
the minutest of the moist rales, and have been by some 
writers described as belonging to the dry type. They 



AUSCULTATION. 127 

have a fine, somewhat dry, crackling' sound, similar to 
that produced by slowly and firmly rubbing a lock of 
hair between the ringer and thumb close to the ear. At 
times they have a sharpness that resembles the sound- 
produced by the crackling of salt thrown upon the fire, 
or the sound gives an impression of stickiness as when 
the moistened thumb and finger, having been pressed 
together, are separated close to the ear. 

Their pitch is high and they convey the impression 
of being produced near the surface. They occur in 
showers or explosions and are of uniform size. 

They are persistent at the spot first heard, not being 
removed by coughing, and are usually restricted to in- 
spiration, although they may at, times Ik- heard 
momentarily just at the beginning of expiration. Some 
authors state that they may be heard only during expira- 
tion. Formerly it was claimed that one of the dis- 
tinguishing features of the crepitant rale was that it 
occurred only during inspiration and that any rale 
bavins: the same general characteristics, but occurring 
during expiration, could not be a crepitant rale. 

There are differences of opinion as to the place and 
mode of production and diagnostic significance of the 
crepitant rale. Some claim that they are intrapul- 
monary, being produced in the ultimate bronchioles and 
alveoli and due to the separation of the walls of the 
alveoli which were more or less firmly agglutinated by 
tenacious secretions. Others claim they are caused by 
the bursting of fine bubbles formed by the forcing out, 
during* inspiration, of the secretions from the bron- 
chioles into their infundibuli. Others believe that they 
are extrapulmonary and are made in the pleura, being, 
in fact, the finest of friction sounds. 

The facts that seem to uphold the latter theory are 
their remaining at the spot where first heard, not being 
influenced bv coughing, that they are usually heard 
only with inspiration but may occur with expiration, 
and that a forcible pressure by the ear or stethoscope 



128 THE RESPIRATORY SYSTEM. 

upon the chest wall during expiration will often cause 
them to be heard with expiration when before they were 
only detected with inspiration. While production of the 
crepitant rales in the bronchioles and alveoli is possible 
their pleural origin is more probable. 

These rales have a special importance, as they have 
been considered diagnostic of the first stage of croupous 
pneumonia, occurring even before changes in the res- 
piratory murmur. In this disease they have also been 
called the "rale indux," and confusion has occurred by 
considering: them also the "rale redux." 

They occur also over the seat of catarrhal pneumonia,, 
caseous tubercular pneumonia, infarctions, oedema of 
the lung and atelectasis. 

Crepitations are frequently heard at the base of the 
lung in persons who have been long confined to the re- 
cumbent posture, and in those in whom there has been 
superficial breathing. Bales due to these causes disap- 
pear after two or three full breaths have been taken. 

Classification of Moist Rales. — The most rational di- 
vision of the moist rales is, according to their size, into 
small, medium and large rales. 

Appreciation of the size of a rale is important, as it 
indicates (a) the size of the bronchus in which the 
sound is made; (b) it is diagnostic of the extent of the 
disease, and whether or not further pathological changes 
have occurred beyond the mere presence of more or less 
fluid secretion in the tubes. 

The size of the rale should always be considered in 
conjunction with its intensity and nearness to the ear. 
The larger the rale, the larger should be the space in 
which it is made, and consequently it should give the 
impression of being more or less distant from the 
surface. 

If, on the other hand, there is heard over a region 
where the bronchi are normally small, as at the apex or 
base, fairly large-sized rales which at the same time 



AUSCULTATION. 129 

appear to be close to the surface, it indicates that there 
has occurred dilatation of the bronchi (bronchiectasis), 
or destruction of pulmonary tissue, and the formation of 
cavities of greater or less extent. 

The small moist rale, in addition to its size, differs 
from crepitations or the "crepitant rale" in the follow- 
ing: (a) The liquid character is more marked. 
(b) While heard chiefly with inspiration, it is also 
present during the first part of expiration, and may 
persist throughout, (c) It is influenced by coughing, 
at times disappearing when the bronchi are clear of 
their fluid contents; at other times appearing when the 
secretion is forced from the alveoli into the bronchi. 

The designation by some authors of these relatively 
large moist rales as "crepitant" has led to much con- 
fusion. 

The moist rales are divided into two groups, accord- 
ing to the quality of their sound. 

While both groups of the small moist rales are due to 
the presence of fluid secretion in the air-containing 
spaces, the difference in the quality of sound is de- 
pendent upon the condition of the pulmonary tissue, its 
influence on the conduction of the rale sound to the sur- 
face, and on its power to modify the sound. 

(1) When the pulmonary tissue is normal the moist 
sound made in the bronchi is modified, as is the bron- 
chial sound that is normally present at the site where 
the rales are made, and they are heard at the surface as 
soft liquid or bubbling sounds. 

Authors have used the terms "bubbling," "liquid," 
"mucous," "submucous," "non-ringing," "non-consonat- 
ing" ("klanglos") to describe the sound. 

(2) When there are present changes which increase 
the power of conduction by the tissues, or produce a 
resonating effect, as occurs in increased tension (chil- 
dren), or in pulmonary consolidation due to increase of 
tissue, or the filling of the air spaces by solid exudate 
(pneumonia, tuberculosis, etc.), the rales will be heard 

9 



130 THE RESPIRATORY SYSTEM. 

at the surface with increased sharpness. They will 
have a higher pitch and a crackling, explosive or ring- 
ing quality. 

Hence the names "dry," "crackling," "crepitating 
moist rale/' "humid crackling/' "explosive moist rale," 
"subcrepitant," "ringing," "consonating" ( "klingend" ) , 
given to describe this character of sound. 

Rales in group 2 are usually associated with percus- 
sion, palpation and auscultatory signs that indicate the 
pathological conditions. 

When this type of rale is not attended by these con- 
firmatory signs, the quality is due to the tenacious 
character of the secretions. 

The largest of the moist rales have received several 
names to denote their association with certain patho- 
logical conditions. 

Gurgles are produced in cavities partially filled 
with fluid, where the bronchus enters below the level of 
the fluid. They may be present during inspiration and 
expiration, or may be induced only by coughing. They 
are large, liquid, bubbling sounds, with a peculiar 
hollow ringing quality, which distinguishes them from 
other moist rales of the same size. 

Mucous clicks are sounds which may be imitated by 
whispering the word "click." They generally occur 
singly, and are short, snappy, sticky sounds, heard only 
during inspiration. Their mode of production is still 
in doubt, but they are generally associated with soften- 
ing of tubercular deposits. This term is gradually fall- 
ing into disuse, as these rales are not considered to have 
the diagnostic significance which was formerly given 

them. 

Metallic tinkle is a single loud, high-pitched 
sound, with a marked echo quality, and is produced in 
large cavities with thin, tense walls. The peculiar echo 
quality of the sound is due to reflection or reverberation 
in the cavity. While heard with greatest distinctness 
in pyopneumothorax, it may occur over a large pul- 
monary cavity, when it is called "amphoric echo." 



AUSCULTATION. 131 

Succussion sound is a splashing sound that occurs 
when the pleural cavity contains air and fluid and is agi- 
tated. 

This sign may be induced by giving the patient a 
quick, short shake, or by coughing. While the sign is 
present in pneumo-hydro- and pneumo-pyothorax, it 
may occur in cavities of the lung when of large size 
and filled with fluid. 

(3) Friction Sounds. — In normal conditions the move- 
ment of the two surfaces of the pleura on each other is 
unattended with any sound, but in di>ea>ed conditions 
rales of various kinds may be produced. 

(a) Dry Frictioxs or Crepitations. — When the 
surface becomes abnormally dry, the to-and-fro move- 
ments are attended with a dry rubbing sound, similar to 
that produced when the dry surfaces of the hands are- 
passed lightly over each other, or it may be like the 
crepitations described above under moist rales. 

Dryness of the pleura occurs during the first stage of 
its acute inflammation and when a large amount of fluid 
has been lost from the body, as in excessive diarrhoea of 
the choleraic type. 

(b) Moist Crepitatioxs. — When the pleurae are 
covered with a tenacious secretion which glues the two 
surfaces together, their separation is accompanied by 
sticky, moist, crackling, crepitating rales. This type 
frequently replaces the dry rales as the plastic exuda- 
tion is poured out after the first stage of inflammation. 

(c) RuBBIXG, RaSPIX'G, GrATIXG, GrAZIXG, CrEAK- 

ixg, Leathery Souxds. — These occur when the sur- 
faces of the pleura are roughened by exudation, by in- 
flammatory changes or "joined together bv bands of 
adhesions. These rales may be felt by the patient, or 
detected by the hand or ear as fremitus. 

As the pleural rales depend upon the movement of the 
thorax thev will be heard with the greatest intensity 
over the lower segment of the thorax at the end of 
inspiration and at the beginning of expiration, as the 



132 



THE RESPIRATORY SYSTEM. 



play of the pleura is greatest during these portions of 
the respiratory act. 

When due to a sticky exudation, deep breathing fre- 
quently causes the rales to disappear. They can be 
heard again after quiet breathing and when pressure is 
made on the chest wall so as to increase the friction. 



Differentiation of Pleural from Bronchial 

Rales. 

In certain cases it is impossible, by the quality or size 
of the rale, to separate the pleuritic from the bronchial 
rales. 



Pleural. 



Localized. 



Generally unilateral. 

Frequently accompanied by 
pain. 

They give the impression of 
being produced close to the ear. 

Usually increased by cough- 
ing or deep breathing. 

They are localized at the 
point where first heard. 

Their intensity may be in- 
creased by pressure upon the 
surface. 

Occur in showers or bunches, 
and all of uniform size. 



Bronchial. 

Not generally localized, but if 
so, they are associated with 
signs of bronchitis, or consoli- 
dation. 

Very apt to be bilateral. 

Generally no pain. 

They seem more or less dis- 
tant from the surface. 

Frequently disappear after 
coughing or deep breathing. 

The location changes fre- 
quently as the result of 
coughing. 

Unmodified by such pressure. 



Various sizes may be heard 
at the same time. 



It must be borne in mind that pleuritic and bronchial 
rales may be present at the same time. 

(4) Indeterminate, or Indefinite Rales. — In addition to 
the dry, moist and friction rales, another class has been 
recognized under the title of "indeterminate" or "indefi- 
nite" rales. They are crepitating, crumpling, crack- 
ling sounds, moist or dry, heard over various portions 



AUSCULTATION. 133 

of the thorax during inspiration, expiration, or both. 
The origin and mode of production of their sound are 
doubtful. 

They include the muscle sounds and the so-called 
emphysematous crackle. Some authors include in this 
class all rales that cannot be definitely determined as 
bronchial or pleuritic in origin. 



CHAPTER VI. 

AUSCULTATION (CONTINUED) 



(A) CONDITIONS MODIFYING AERIAL VIBRATIONS 

AND CONDUCTION OF SOUND BY THE 

COLUMN OF AIR. 

Movement of Tidal Air 

As the respiratory sounds depend primarily upon 
the movement of air through the glottis and bronchial 
tract, they will be influenced by the amount of tidal air, 
the force of the current, and the rapidity of its move- 
ment. These factors will influence chiefly the vesicular 
quality of inspiratory sound and the intensity and dura- 
tion of both respiratory sounds. 

When the breathing is deep, and at the same time 
more rapid than normal, the inspiratory sound is 
sharper in quality and more intense, while the expira- 
tory has a more blowing quality and its intensity is 
accentuated. When the muscles of expiration aid the 
normal elasticity of the lungs the duration of the 
expiratory sound may nearly equal that of the inspira- 
tory. When this type of breathing is general, it is 
called exaggerated breathing. 

When the respiratory function of one lung is inter- 
fered with from any cause, as pneumonia, pleurisy with 
effusion, etc., and the unaffected lung is doing more 
work in consequence, the breathing over the unaffected 
side is called compensatory breathing. 

Exaggerated or compensatory breath sounds may be 
limited to one lobe, as when pneumonia affects the other. 
They may be limited to a portion of a lobe. This occurs 



AUSCULTATION. 135 

(a) when a bronchus is plugged, or (b) when some of 
the lobules are filled with inflammatory exudate. In 
such cases the unaffected lobules on this division of the 
bronchial tree accommodate not only their own normal 
quantity of tidal air, but also that which should go to the 
affected part, and not only is the current stronger but 
there is overdistension of the alveoli, increased tension 
and resultant change in the vesicular murmur. 

Localized exaggerated breathing in any portion of the 
lung always indicates compensatory action and is there- 
fore an important diagnostic sign. 

Conditions which diminish the amount of tidal air, 
weaken its force, or slow the current, will cause a dimi- 
nution of the breath sounds heard at the surface. 

These conditions may be due to changes (a) in the 
bronchial tract, as in certain stages of bronchitis; (b) in 
the parenchyma of the lung, as in emphysema; (c) in 
the pleura, as adhesions or fluid; (d) in the bony 
thorax, as increased rigidity; (e) in the soft parts, as 
feeble muscular action. 

In some individuals the normal vesicular murmur is 
so faint during quiet breathing that it can scarcely be 
appreciated. This may be due to the manner of breath- 
ing or to anatomical conditions of the larynx. In such 
cases it is necessary for the patient to take deep breaths 
in order to obtain the breath sounds. 

Influence of the Larynx. 

As has already been noted (page 108), the normal 
vesicular murmur will vary within wide limits, but will 
always have a definite relation to the character and 
intensity of the sound heard over the glottis, which 
forms the basis of all breath sounds present in the 
lung; so that as each voice has its own individual 
quality by which it is recognized, so also will the char- 
acter of the respiratory sounds differ. Therefore, when 
the question arises whether or not the breath sounds are 
within the range of normal the laryngeal sound should 
always be taken as a guide. 



136 THE RESPIRATORY SYSTEM. 

Morbid conditions of the larvnx will modify the 
breath sounds in either inspiration or expiration, or in 
both. 

As has been shown, the inspiratory portion of the 
vesicular murmur is composed not only of sounds made 
in the larynx but also of those made in other portions 
of the bronchial tract and at the alveoli, while the 
expiratory portion depends entirely on the conduction 
to the surface of the sound made at the larynx. There- 
fore, any changes made in the character or intensity of 
the glottic sound will be most marked in the expiratory 
murmur. 

The laryngeal sounds may be increased by anything 
which narrows the opening or changes the relation of the 
parts. The change in the breath sounds may be 
limited to one or both portions of the respiratory act. 
Narrowing of the glottis, depending upon malignant or 
non-malignant growth, tuberculosis and syphilis may 
cause greater or less change in the quality of the sound, 
so that the respiratory murmur heard at the surface of 
the chest will have a peculiar harsh, blowing quality. 
Paralysis of the vocal cords diminishes the size of the 
lumen of the glottis and produces change in the quality 
of the sound but it is not as marked as in morbid 
growths, and while the quality of the sound is changed, 
it lacks the harshness. Inflammatory thickening and 
exudations (oedema glottidis) produce the same changes 
as new growths. Croup (laryngeal diphtheria) and 
spasmodic conditions of the larynx produce a form of 
stridor which, on account of its musical quality, may 
mask the vesicular element of the breath sounds so that 
the only sound heard over the surface of the chest will 
be more or less bronchial in type. It must be especially 
remembered that the introduction into the larynx of 
intubation tubes, or the presence of a tracheotomy tube, 
may cause the breath sound heard over the lung to be 
distinctly tubular. This frequently causes the diag- 
nosis to be made of secondary pneumonia and a cor re- 



AUSCULTATION. 137 

spoil* ling gloomy prognosis in cases of diphtheria in 
young children. 

The laryngeal sound will be diminished by condi- 
tions which will hold apart the vocal cords. 

Especial care must be taken in judging of the pul- 
monary condition .by auscultatory signs when disease of 
the larynx is present, which causes a diminution of the 
glottic sound, as the effect of changes in the laryngeal 
sound may be so marked as to prevent bronchial breath- 
ing being produced in well-marked consolidation of the 
lungs. 

Influence of the Bronchi. 

The condition of the bronchial tubes may modify the 
respiratory sounds in their normal elements or add new 
sounds, as adventitious sounds of rales. (Figs. 25 
and 26.) 

When the lumen of the tubes is narrowed, either by 
congestion, as in acute bronchitis, by growths within or 
by pressure from without, the intensity of the murmur 
over that portion of the lung which they supply with air 
may be increased or diminished, according as the 
amount and movement of tidal air is influenced. When 
the narrowing; causes no diminution in the amount of 
air passing in the lung beyond, then, on account of the 
narrowing, the movement of the air through the nar- 
rowed portion will be more rapid and forcible, inspira- 
tion will be harsher in character, while expiration will 
be more blowing, higher pitched and of longer duration. 

If, on the other hand, changes in the bronchi inter- 
fere with the movement of air so that it reaches the 
bronchioles reduced in amount and force, inspiration 
will be feeble, the vesicular elemnt especially weak, and 
expiration perhaps inaudible. 

Diminution in the intensity of the respiratory mur- 
mur is most marked when the smaller bronchi are in- 
volved. These changes in intensity may be bilateral 
or limited to one lung or a portion of one lung, accord- 
ing to the morbid processes. 



138 TBE RESPIRATORY SYSTEM. 

The abnormal or adventitious sounds present in dis- 
eases of the bronchi are the dry and moist rales, accord- 
ing to the changes in the bronchi and nature of their 
contents. 

Dry Rales. — When the lumen of a bronchus is so 
abruptly narrowed, either by contraction of the muscu- 
lar fibres or by thick, tenacious secretion, as to produce 
conditions like those of a wind instrument, as the tidal 
air passes over the obstruction into the relatively wider 
lumen beyond, vibrations are set up and a sound pro- 
duced as in the larynx at the glottis. 

The character of the sound will depend upon the 
degree of narrowing, the size of the tube and the force 
of the current, and the adventitious sound will be added 
to or modify that made at the glottis. 

The character of the sound will depend upon the 
degree of narrowing, the size of the tube and the force 
of the current, and the adventitious sound will be added 
to or modify that made at the glottis. 

When the narrowing is relatively slight, the sound 
produced will be of a harsh, blowing, non-musical char, 
acter, similar to that made normally at the larynx. At 
the surface it will have a well-marked bronchial charac- 
ter, most marked with expiration, and almost identical 
with that heard when the lung is consolidated, from 
which it is differentiated by the signs noted by per- 
cussion and palpation. This sound mayoccur in bron- 
chitis, asthma and pulmonary tuberculosis. In the lat- 
ter disease it may be associated with more or less con- 
solidation. 

Wh'en the narrowing is more marked, the sound will 
have a more musical quality, being a type of stridor 

already described. 

When the constriction is in a tube of the second or 
third division, it produces a deep-toned, low-pitched, 
musical sound (sonorous rales). 

When in the smaller tubes, the sound is shriller, 
higher pitched, whistling (hissing or sibilant rale). 



AUSCULTATION. 139 

The division into sonorous and sibilant rales is an 
arbitrary one, and one type merges into another, accord- 
ing to the size of the tube and nature of the obstruction. 

The dry rales are not permanent, being evanescent, 
appearing and disappearing; now being heard at one 
place, then over another area. 

The effect of these rales on the normal respiratory 
murmur varies according to their number and intensity, 
and whether or not the constriction is so marked as to 
interfere with the movement of tidal air and prevent 
the production of the normal vesicular element. 

The persistence of the vesicular sound is an impor- 
tant diagnostic sign, indicating the degree of obstruc- 
tion. Students frequently fail to appreciate the vesicu- 
lar murmur even when present, as the sibilant and 
sonorous sounds are so striking as to engross the atten- 
tion. 

The special significance of these rales being heard in 
inspiration or expiration, or limited to one or the other, 
will be considered under the diseases. 

Moist Kiles. — When the bronchi are more or less filled 
with fluid, there will be present the different varieties 
of moist rales that have already been described (page 

125). 

The conditions that produce dry and moist rales may 
affect the entire bronchial tract, as in general bronchitis, 
or may be limited to one lung or to a portion of a lobe. 
The wide or limited distribution of the adventitious 
sounds is of important diagnostic value. 

The Effect of Plugging of a Bronchus .— Complete 
closure of a bronchus by compression from without, as 
by an enlarged gland or aneurism, by the plugging with 
secretions or plastic exudation as in bronchitis and 
pneumonia, or by a growth within the tube as in tuber- 
culosis, produces marked diminution or complete ab- 
sence of the breath sounds, according to the site of the 
obstruction. It influences the production of sound by 
the tidal air and the transmission by the tissues. Vibra- 



140 THE RESPIRATORY SYSTEM. 

tions that are present in the column of air are arrested 
at the point of occlusion, and as there is no movement 
of air beyond that point no sound is made at the junc- 
tion of the alveoli with the infundibuli, and conse- 
quently the vesicular quality of the respiratory murmur 

is wanting. . 

Important changes occur in the area that is supplied 
by the occluded bronchus. The air beyond the obstruc- 
tion is rapidly absorbed, and when the plug acts as a 
ball valve the air may be forced out during expiration 
but not replaced during inspiration. Kemoval of air 
causes relaxation of the lung and more or less complete 
atelectasis. As will be shown later this loss of tension 
causes the tissue to be a poor conductor of vibrations 
and Hie expiratory portion will be especially feeble or 

absent. 

When a large bronchus is occluded no sound will be 
heard over the portion supplied, so that even bronchial 
breathing may be absent in complete consolidation of the 
lung, as in croupous pneumonia. If a small branch 
only 'is involved then feeble breath sounds may be heard 
over the affected area and, the surrounding portion of 
the lung being overdistended, exaggerated or compen- 
satory breathing is present. (Fig. 34.) 

(B) CONDITIONS MODIFYING TISSUE VIBRATION 
AND THE CONDITION OF SOUND 
BY THE TISSUES. 

The Influence of Tension.— The elasticity of the tissues 
of the respiratory tract and their degree of tension has 
an important effect not only on the intensity but also 

on the quality and P itcn of ihe breath s0lincls - 

When the elasticity and tension are increased the 
tissues are more easily influenced by the aerial vibra- 
tions present in the bronchi and air spaces. The vibra- 
tions are shorter, the tissues become better conductors 
of sound, the inspiratory sound is consequently more 
intense, has a sharper vesicular quality and the pitch 



AUSCULTATION. Ill 

will be slightly raised. The expiratory sound is louder, 
more intense, longer, has a more marked blowing qual- 
ity, often with a suspicion of a bronchial element. Age 
has an important effect on the elasticity and tension of 
the respiratory apparatus. In the child not only is 
the resiliency of the tissues greater, but up to twelve 
years of age the relatively more rapid development of 
the thorax than the lung causes the tension to be much 
greater than in the adult and is one of the factors that 
causes the respiratory sounds in children to be dis- 
tinctive enough to be called "puerile breathing" and 
stand out as a type. 

Exaggerated or compensatory breathing is due to 
increased tension as well as to changes in the volume 
and force of the tidal air. 

With advancing years and when pathological changes 
occur, as in emphysema, there is a loss of elasticity and, 
although the lung may be distended bevond the normal, 
there is a lowered tension and the respiratory sound- 
are feeble and lower pitched; inspiration is shorter, 
while expiration is prolonged. 

Influence of the Increase of Tissue in the Walls of the 
Bronchi and Alveoli on the Respiratory Sounds. — When 
considering the production of normal vesicular murmur 
it was stated that the thin, membranous structure of the 
Avails of the bronchioles and alveoli was chiefly influ- 
enced by the vibrations of the air contained in them, 
also that this tissue was a poor conductor of the vibra- 
tions brought to it from above through the more solid 
tissues of the walls of the bronchi, and that these facts 
accounted for the absence of the bronchial or tubular 
sound in the normal respiratory murmur. 

When the normally light membranous structure of 
the periphery of the lung is changed into denser con- 
nective tisue, as occurs in interstitial or fibroid 
changes in the interlobular septa (interstitial pneumo- 
nia, fibroid phthisis and certain types of pulmonary 
tuberculosis), the new tissue, being more homogeneous 



142 THE RESPIRATORY SYSTEM. 

with the walls of the larger bronchi, will conduct the 
bronchial sound from the deeper portion of the lung 
direct to the surface. The change may be so slight as 
only to give a slightly prolonged expiration. The ear 
may detect two types of breathing in varying propor- 
tions — the normal vesicular murmur and an added 
bronchial element, most marked in expiration. This 
mixed breathing is called broncho-vesicular. The pro- 
portion and character of the tubular quality will depend 
upon O) the amount of new tissue; (b) the extent of its 
penetration into the lung and the size of the bronchial 

tubes reached. , 

Broncho-vesicular breathing varies from the faintest 
tinge of the bronchial sound to that in which the tubular 
sound predominates, and the vesicular element can only 
be faintly detected. (Fig. 34.) 

When the air in the alveoli is replaced by coagulated 
exudate or tissue, as occurs in pneumonia, hemorrhagic 
infarction and tubercular infiltration, then during in- 
spiration the vesicular quality is absent because there 
is interference with the amount and force of tidal air, 
and the aerial vibrations are unable to modify the tissue 
vibrations present. The consolidated lung, being a good 
conductor, allows the bronchial sound present m the 
deeper portion of the lung to be heard. 

When the consolidation is very slight the sound from 
both the normal and consolidated lung is brought to the 
surface, so that the only change noted may be limited to 
a prolongation of expiration, with a slight raising of the 
pitch, i. e., the faintest type of broncho-vesicular breath- 

insj. 

If the consolidation reaches only to the small bronchi 
then the breathing, while bronchial, is of a soft, blowing 
quality, the pitch is raised, the intensity corresponds to 
the pitch, and the expiratory sound is prolonged, more 
tubular and higher pitched than the inspiratory, and a 
short pause is noticed between inspiration and expira- 
tion. 



AUSCULTATION. 14 



Q 



When a medium-sized tube is involved the quality 
will be more bronchial, the pitch will be higher, the 
intensity greater, the expiratory sound will be higher 
pitched and longer than the inspiratory, and will have 
a more markedly tubular character. This is usually 
described as bronchial breathing. 

When an entire lobe is involved, then the sound heard 
is that conveyed from the large bronchi. It has all of 
the characteristics of that heard normally over the 
trachea, and is called pure bronchial, tracheal or tubular 
breathing. 

The auscultatory signs heard at the surface in con- 
solidation of the lung, whether due to fibrosis of the 
stroma or filling of the air spaces, are not always as 
typical as has just been described. 

When the consolidated portion reaches the surface, 
and is immediately beneath the ear, then the breathing 
will be typical of the pathological changes. 

When the consolidation is deeper and is covered by 
lung that is normal, or in a state of compensatory 
distension, the bronchial element may be entirely 
masked by the normal or exaggerated breath sound of 
the overlying portion of the lung, or it may be faintly 
detected/ especially in expiration, where the first part 
has a fairly normal quality but the latter part is pro- 
longed, high pitched, more blowing and bronchial. (Fig. 
34.) This type of breathing, according to the intensity 
of the bronchial sound, as has been described as ''broncho- 
vesicular breathing," "prolonged, high-pitched expira- 
tion" or one of the" types of the so-called ^metamorphos- 
ing breathing." 

"The influence of changes occurring in the pleura on 
the bronchial breathing of consolidation will be con- 
sidered later. 

Influence of the Increase in the Size of the Air-Containing 
Spaces (cavity formation and bronchiectasis). — The destruc- 
tion of lung tissue and the formation of cavities, which 
are at least partly empty and connect freely with a 



144: THE RESPIRATORY SYSTEM. 

bronchus, cause a modification of the bronchial breath- 
ing which is called cavernous or amphoric, according to 
the dimensions of the cavity, the condition of the tissue 
forming its walls and the size of the bronchus opening 

into it. 

Much confusion will be avoided if it be remembered 
that bronchial, cavernous and amphoric are all types of 
tubular breathing; that they vary only in degree and 
often approach each other in character. While they 
have a general resemblance the differentiation is made 
by the quality and pitch of the sound. 

The bronchial sound that is brought to the cavity is 
resonated, as when one blows over the mouth of a bottle. 
When the walls of the cavity are flaccid and of low ten- 
sion, a peculiar hollow sound is produced which is called 
cavernous. The inspiratory portion is soft, blowing, 
hollow, but less tubular and lower pitched than the 
tracheal sound. The expiratory is more blowing, wavy 
or puffy ; the pitch is lower than that of the inspiratory, 
which distinguishes it from bronchial breathing, in 
which the pitch of expiratory is higher than that of the 
inspiratory sound. 

The sound heard over the trachea, behind, serves as a 
standard for bronchial breathing with which to compare 
doubtful cavernous breathing. 

When the walls of a cavity are rigid and tense, ae 
when composed of dense, fibrous tissue;) when sur- 
rounded by consolidated lung; or when bound to the. 
chest wall by firm pleuritic adhesions, the sound pro- 
duced is called amphoric. It is a hollow, blowing 
sound, similar to the cavernous, but has a harsh, metallic 
or slight echo quality. The tubular element is more 
marked but less than in bronchial breathing, and the 
expiratory sound has a lower pitch than that of inspira- 
tion. 

The terms cavernous and amphoric, used to designate 
the breath sounds heard over cavities, are sometimes 
uncertain in their application, owing to the individual 



AUSCULTATION. 145 

interpretation of the sound heard. This is due to the 
fact that the walls of cavities vary in tension. A type 
of breath sound is frequently heard which has the quali- 
ties of the cavernous and amphoric breathing in vari- 
ous degrees, and may be called caverno-amphoric or 
amphoro-cavernic, as either type predominates. 

When the cavity is filled with fluid or the bronchus 
leading to it is occluded, cavernous or amphoric breath- 
ing may be absent, either temporarily or permanently. 

When a bronchus opens freely into the pleural cavity 
filled with air, a peculiar, intense type of amphoric 
breathing is heard. This has been called the "lung 
fistula sound." 

(C) CONDITIONS MODIFYING VOCAL RESONANCE. 

The difference in the sounds heard over the chest 
when a person breathes, whispers or speaks depends 
upon the character of the vibrations made at the glottis. 

Whispered Voice or Whispered Resonance. 

In order to intensify the sound made at the larynx, 
the patient may be instructed to breathe noisily, or, 
what is better still, to whisper with different degrees 
of loudness. The whispered voice, in addition to being 
more intense than the breath sound, saves the articu- 
late elements of speech — the consonants. The clearness 
with which they are heard over the different regions of 
the chest indicates the extent and degree of the changes 
that have occurred in the power of the lung to conduct 
sound to the surface. 

The whispered voice is heard with expiration, and 
when patients are too weak to take deep breaths we can 
increase the intensity of the sound heard on expiration 
without exhausting the patient by having him whisper. 

Xormally, the whispered words are conveyed to the 
ear as soft, diffuse, indistinct sounds. Over those por- 
tions of the lung where tracheal, laryngeal and bronchial 

IO 



146 TEE RESPIRATORY SYSTEM. 

breathing normally exist, the whispered words are heard 
with greater distinctness and the words will be recog- 
nized more or less completely. 

Conduction of the whispered voice will be increased 
or diminished in the same manner and under like condi- 
tions as the breath sounds. It is especially valuable to 
determine the presence of a slight amount of consolida- 
tion, when the whispered words will be brought to the 
ear with increased distinctness. 

As consolidation increases in extent and involves the 
larger tubes, the whispered words become more and 
more distinct, until it is possible not only to recognize 
the whispered words or numbers (whisper-bron- 
chophony), but also to detect the articulate parts of 
speech, as the consonants (whisper-peetoriloquy). 

The Spoken Voice or Vocal Resonance. 

The vibrations of the spoken voice are so powerful 
as to influence the entire amount of air within the 
bronchi and alveoli, so that they are not only heard at 
the periphery as normal resonance, but are also felt as 
fremitus. The open bronchi, with their tense elastic 
walls, act as speaking tubes and the sound made at the 
glottis is modified in its conduction to the surface, as 
follows: (1) By reflection, reverberation or echo 
within the tubes, so that confusion of the sound occurs. 
(2) By diffusion in the ramifications of the bronchi 
and alveoli, so that it becomes weaker or less intense. 

In the larynx and trachea little change occurs in the 
sound, except that the consonants are not heard as 
distinctly, but the intensity of the sound seems to be 
slightly greater than at the mouth. 

In the larger bronchi, as heard over the sternum and 
parasternal portion of the infraclavicular space in front, 
and upper portion of the interscapular space behind, the 
sound is more indistinct, the words are blurred, but still 
distinguishable, and the pitch of the sound is slightly 
higher than in the trachea. This sound is called normal 



AUSCULTATION. 147 

broncho phony, and may be heard over other regions of 
the chest when consolidation of the lung tissue transmits 
it unmodified to the surface. 

With each division of the bronchi the sound is still 
further reflected, confused and weakened, as were the 
breath sounds, until at the surface of the lung the 
articulate parts of speech are absent, the words are not 
distinguishable, and it becomes an indistinct humming, 
buzzing sound, normal vocal resonance. 

Normal vocal resonance will vary in individuals, ac- 

* 

cording to the character of the voice, as has been men- 
tioned under "Palpation." 

It will be influenced by the same changes in the 
bronchi and alveoli that modify the fremitus of palpa- 
tion and the breadth sounds. 

Vocal resonance may be absent, feeble or exaggerated. 
Just as in proportion to the pulmonary consolidation, 
the expiratory part of the respiratory murmur varies in 
intensity, pitch and quality, from the faintest suspicion 
of bronchial soimd up to pure bronchial breathing, so 
vocal resonance varies in the clearness with which the 
articulate sounds are heard from a slight increase of 
normal resonance up to bronchophony, where the words 
are heard more or less distinctly, but confused and asso- 
ciated with vibrations of the chest wall. 

Pectoriloquy, as its name implies, sounds as if the 
patient was speaking directly through the chest or as if 
we were listening directly over the larynx through a 
solid medium, as a block of wood. It is an exaggerated 
form of bronchophony. Its characteristic feature is the 
remarkable distinctness with which the consonants of 
the spoken words are heard. It is best detected with 
the whispered voice, as there is less confusion from 
reverberation. 

Pectoriloquy is heard over consolidated lunsr that is 
m a high state of tension, and that extends to the laroe 
bronchi. 

Over pulmonary cavities two kinds of spoken and 



148 THE RESPIRATORY SYSTEM. 

whispered resonance are heard: (a) cavernous and (b) 
amphoric. 

Cavernous resonance is produced in cavities with 
thin lax walls. It is a type of bronchophony. The 
sound is hollow, low pitched, and has a puffing, blowing 
character. With the spoken voice the words are con- 
fused, having a slight echo quality. With the whispered 
voice the words are more distinct, but not articulate. 

Amphoric resonance occurs in cavities with tense 
walls, and is usually associated with amphoric breath- 
ing. The sound is a type of pectoriloquy, in that it is 
distinctly axticulate, with a hollow, ringing, well- 
marked echo quality and high pitch. 

iEooPHONY is a form of vocal resonance that occurs 
in certain stages of effusion in the pleural sac. The 
voice is not as intense as in bronchophony, but is high 
pitched, tremulous, with a. marked nasal sound, so that 
it has been compared to the bleating of the goat; but it 
is more like the voice of a person with a cleft palate. 
It is not associated with increased vocal fremitus. _ The 
condition of the lung allowing its production will bo 
considered under "Pleurisy with Effusion." 

Auscultation of the Cough. 

The sound produced by coughing is frequently util- 
ized in diagnosis, but it is not as reliable as vocal reso- 
nance. In the normal lung it is heard at the surface as 
an indistinct, sharp sound, accompanied by sudden 
movement of the chest wall, due to the action of the ex- 
piratory muscles. In varying degrees of pulmonary 
consolidation and in cavities it has been named bron- 
chophonic, cavernous and amphoric cough, having the 
same features as vocal resonance under similar condi- 
tions. 

On account of the forcible expulsive power of cough, 
a larger amount of air than usual is driven out of the 
lung and the succeeding inspiration is correspondingly 
increased in volume. This allows slight changes in the 



AUSCULTATION. 14:9 

bronchi and pulmonary tissue to be detected by the 
character of the vesicular murmur. "A post-tussive 
suction sound" or "india rubber-ball sound" is fre- 
quently heard with, the inspiration immediately after 
the cough when cavities with soft, yielding walls are 
present. It is a sucking, semi-sonorous, low-pitched 
sound, usually accompanied by a few mucous clicks or 
medium-sized moist rales. It is a very important and 
reliable sign of cavity formation. 

Coughing has a marked effect on moist rale-. When 
the fluid contents of the tube are dislodged it may cause 
them to disappear entirely or to change small rales to 
those of larger size. When the secretion is in small 
cavities, with more or less occlusion of the bronchial 
tubes leading to them, no rales may be detected (luring 
quiet or even forcible breathing, but are heard after 

coughing. 

The Bell Sound, Bell Tympany, or Coin Reso- 
nance. — In pneumothorax, or when a large cavity is 
present in the lung close to the surface, if percussion is 
made on the anterior portion of the chest with two 
coins while the auscultator listens behind, there is heard 
over the affected area a distinct ringing bell- or anvil- 
like sound. In order that this air-containing space may 
act as a resonator, it is necessary that it be of a certain 
size, with tense walls. This test is frequently made by 
snapping or flicking the chest wall with the finger and 
thumb. Over normal lung the "flick" will be heard as a 
dull thud, but in pneumothorax a clear, ringing, 
chiming sound is heard whenever the air-containing 
area is reached. 

Veiled Puff. — This is a short, high-pitched, puffing 
sound, which is added to the inspiratory murmur toward 
the end of inspiration. It has been considered diag- 
nostic of small sacculated bronchiectatic cavities. 



150 THE RESPIRATORY SYSTEM. 

(D) INFLUENCES OF CHANGES IN THE PLEURA 
ON THE BREATH SOUNDS. 

The normal pleura, being very thin and almost homo- 
geneous with the tissue of the walls of the alveoli, does 
not affect the transmission of the respiratory sounds. 
When the pleura is thinly covered with a sticky secre- 
tion, different varieties of friction sounds are beard, 
which may mask the pulmonary sound. 

When the pleural changes cause pain on breathing, 
movement of the affected side is restricted and there is 
a corresponding decrease in the intensity of the vesicu- 
lar murmur. Generally all increase in the thickness of 
the pleura, whether from plastic exudation or inter- 
stitial changes, interferes with the transmission of 
vibrations to the surface and influences the intensity of 
the breath sounds. 

"The motion of sound, like all other motion, is en- 
feebled by its transmission from a light body to a heavy 
one" (Tyndall), so that the vibrations in the thin mem- 
branous walls of the alveoli are transformed into vibra- 
tions in the thickened pleura, with loss in their intensity 
which is proportionate to the change in the homogeneity 
or density of the pleura. 

Changes in the pleura, especially the pulmonary por- 
tion, which render it less elastic or distensible, curtail 
the normal inspiratory enlargement of the lung and 
thus decrease the amount and force of tidal air and 
enfeeble the breath sounds. This effect is especially 
marked over the apices and lower borders of the lungs. 

Collections of fluid, air or the formation of new 
growths in the pleural sac separate more or less widely 
the two surfaces of the pleura and allow the lungs to 
retract. This produces loss of tension in the pulmonary 
tissue and weakens the vibrations at the surface of the 
lung, so that the breath sounds are heard verv feeblv or 
not at all. 

The occurrence of bronchial breathing and segophony 



AUSCULTATION. 151 

at the upper level of the fluid effusions will be explained 
under "Pleurisy with Effusion." 

Adhesions between the two surfaces of the pleura 
may cause marked decrease in the breath sounds by 
preventing normal movements and limiting expansion. 

When pleural adhesions keep the pulmonary tissue 
tense, or are associated with increase of pulmonary 
tissue, as occurs in interstitial pneumonia and the fibroid 
type of phthisis, they may form homogeneous bands of 
connection between the ribs and the bronchi and so per- 
mit the breath sounds to be heard where ordinarily they 
are absent. 

(E) INFLUENCE OF THE THORACIC WALL ON 

BREATH SOUNDS. 

The bony thorax acts as a sounding beard for the 
vibrations conveyed to it and influences the intensity 
of the breath sounds according to its elasticity. At the 
same time, by its rigidity, it affects the movement of the 
ribs and modifies the amount of tidal air and the inten- 
sity and duration of the vesicular murmur. 

The inspiratory portion of respiration being a mus- 
cular act, its intensity, duration and rhythm are easily 
modified by changes affecting the muscles. 

The rhythm may become irregular, jerky or inter- 
rupted through the imperfect or irregular contraction of 
the ordinary muscles of inspiration. It may be due to 
nervousness of the patient disease of the nervous sys- 
tem or of the muscles themselves, or to pain either in the 
chest wall or in the pleura. 

Expiratory movement, although normally a passive 
act, mav be altered bv the muscles of expiration in the 
same manner as inspiration. 

The thickness of the soft parts will also affect the 
clearness with which the respiratory sounds are heard, 
in a manner similar to its effect on vocal fremitus. (See 
"Palpation.") 



CHAP TEE VII. 

DIAGNOSIS OF DISEASES OF RESPIRATORY TRACT. 



BRONCHITIS. 



Bronchitis is an inflammation of the different tis- 
sues of the bronchial tubes. It may be acute or chronic. 
It may involve a limited portion only, as the large tubes, 
or the entire bronchial tract. Primary acute bronchitis 
usually affects the bronchi of both lungs to a nearly 
equal extent. Accompanying or pre-exi stent disease of 
the lung causes the bronchitis to be limited to a portion 
of one lung only, or to be much more intense on one side 
than on the other. 

Acute Bronchitis. 

The physical signs present in acute bronchitis depend 
on: (1) The size of the bronchial tubes involved. 
(2) The nature and extent of the changes in the mucous 
membrane. (3) The character, amount and distribu- 
tion of the secretion or exudation present in the bronchi. 
(4) The influence of changes in the mucous membrane 
and the presence of secretion on the movement of air in 
the bronchi. 

As the lumen of the bronchial tube has a most impor- 
tant bearing on the intensity of the physical signs and 
the gravity of the disease, it furnishes a basis for classi- 
fication of the varieties of bronchitis. Acute bronchitis 
may be divided into: 

A. Bronchitis of the Larger Tubes. — This includes 
involvement of the trachea and the larger cartilaginous 
tubes, whose diameter is so great that the tumefaction 
of the mucous membrane and the presence of more or 



DISEASES OF RESPIRATORY TRACT. 153 

less fluid secretion or inflammatory exudation does not 
cause marked obstruction or interference with the move- 
ment of air. 

B. Bronchitis of the Middle-Sized Tubes. — An inflam- 
mation of the medium-sized and smaller cartilaginous 
tubes, whose lumen is narrowed to a. greater or less 
extent, with a more or less interference with the move- 
ment of air and a. corresponding production of physical 
signs. Synonyms. — Simple bronchitis, acute bronchial 

catarrh. 

C. Bronchitis of the Smaller Tubes— An inflammation 
of the smallest cartilaginous and non-cartilaginous tubes 
down to the lobular bronchioles and characterized by 
marked obstruction of the bronchi and imperfect venti- 
lation of the lung. Synonyms. — Acute capillary bron- 
chitis, acute suffocative catarrh. 

D. Bronchitis of the Smallest Tubes, including lobular 
bronchi, and extending into the intralobular bronchioles 
and air-passages, with tendency to lobular consolidation. 
This is characterized by extreme interference with pas- 
sage of tidal air to and from the alveoli and with im- 
perfect oxygenation of the blood. Synonyms. — Capil- 
lary bronchitis of infancy and old age; capillary bron- 
chitis with broncho-pneumonia; peripneumonia nothia. 

Physical Signs. — As the classification of bronchitis 
given above is largely arbitrary, and as we rarely find 
the disease limited to the different divisions of the 
bronchi, so also the physical signs that are present in 
one variety of bronchitis merge more or less into those 
of the other varieties. It is best to compare the physical 
signs of the different varieties. 

Inspection. — A. Bronchitis of the Larger Tubes. — 
As there is neither change in the pulmonary tissue nor 
interference with the movement of air through the 
bronchi there is no alteration in the shape and size of 
the thorax. The respiratory movements may be slightly 
increased, both in frequency and depth, but the two 
sides move symmetrically and expansion is full and 
free. 



154 THE RESPIRATORY SYSTEM. 

B. Bronchitis of the Middle-sized Tubes. — In mild 
cases no change is noted in the size or form of the 
thorax and the respiratory movements are but slightly 
increased in force and frequency. In severe cases, in 
proportion to the narrowing of the lumen of the bronchi 
by inflammatory swelling or secretion and interference 
with the free movement of air, the respiratory move- 
ments are more rapid and labored, expansion being re- 
stricted when tubes of smaller calibre become involved 
and the above signs become more marked. 

C. Bronchitis of Smaller Tubes. — There is an in- 
creased movement of the upper portion of the chest with 
violent action of the accessory inspiratory muscles, the 
expansion of the chest is chiefly confined to upper por- 
tion, there is loss of expansion in lower portions of the 
chest, and diaphragmatic action is restricted. As the 
case becomes more severe, and the interference with the 
movement of air through the small bronchi becomes 
more marked, two types of dyspnoea may develop. 

(1) Inspiratory Dyspnoea. In this form the greatest 
interference is with air passing into the alveoli, the 
action of the accessory muscles of inspiration is espe- 
cially great, causing marked elevation of the upper por- 
tion of the chest, while the partial vacuum that is pro- 
duced in the lower portion of the lung causes depression 
of the intercostal spaces, loss of expansion of the lower 
portion of the thorax, and in infants and young children 
yielding of the chest walls, depression of the lower ribs 
and retraction of the abdomen. 

(2) Expiratory Dyspnoea. In this form entrance of 
air into the alveoli is fairly free and the chief difficulty 
is with the tidal air passing out of the alveoli, on ac- 
count of plugging of the small bronchi with secretion or 
to spasm of the bronchi themselves. This gradual over- 
filling of the alveoli (acute emphysema) causes enlarge- 
ment of the thorax, the movements of inspiration are 
short and followed by a, pause, while those of expiration 
are prolonged and labored. During expiration the ac- 



DISEASES OF RESPIRATORY TRACT. 155 

eessory muscles are brought into play and there is bulg- 
ing of the intercostal spaces and superclavicular fossa. 

D. Bronchitis Involving the Lobular Bronchioles and 
Alveoli. — The cyanosis is more marked, the respirations 
are rapid, from thirty to forty and may reach sixty or 
even more per minute. The dyspnoea is chiefly inspira- 
tory, with deep depression of the superclavicular fossa 
and intercostal spaces and, as the bases of the lungs are 
chiefly involved in children, there is marked drawing in 
of the lower ribs, ensiform cartilage and epigastrium. 

Palpation. — A. Bronchitis of Large Tubes. — Sur- 
face temperature slightly raised, respiratory movements 
normal (free, rhythmical and symmetrical), vocal 
fremitus normal, except when larynx is also involved, 
when, it is reduced in direct ratio to the huskiness of 
the voice. 

B. Bronchitis of Middle-sized Tubes. — In mild cases 
the respiratory movements and vocal fremitus are 
within range of normal. In severe cases with marked 
congestion and tumefaction of the mncous membrane 
and thick, tenacious secretion, the movements are 
slightly more rapid and somewhat labored, vocal reso- 
nance is diminished, and when large bronchi are 
plugged there is restricted motion over portion of lnngs 
supplied by occluded tubes and absence of vocal fremi- 
tus. Khonchal fremitus is sometimes present. 

C. Bronchitis of Smaller Tubes. — In mild cases vocal 
fremitus may be normal or slightly diminished. In 
severe cases, in proportion to the obstruction, the move- 
ments will be rapid and labored and vocal fremitus 
feeble or even absent. In children and sometimes in 
adults with thin, elastic chest walls, rhonchal fremitus 

is present. 

D. Bronchitis Involving Smallest Bronchioles and 
Alveoli. — Vocal fremitus is diminished, or even absent, 
when obstruction is extreme. When inflammation has 
extended to the alveoli, causing consolidations of lung 
(broncho-pneumonia) close to the costal surface, vocal 
fremitus may be increased. 



156 TEE RESPIRATORY SYSTEM. 

Percussion. — A. Bronchitis of the Large Tubes. — 
As there is no change in the structure or tension of the 
pulmonary tissue or size of the air-containing spaces, 
percussion sound will be normal in quality, intensity, 
pitch and duration. 

B. Bronchitis of the Middle-sized Tubes. — Percus- 
sion sound is normal unless one of the tubes is plugged. 
If the portion of lung supplied by occluded bronchus 
is in contact with costal surface, the percussion sound 
will have a slight tympanitic quality. If the surround- 
ing portion of the lung that is in state of compensatory 
emphysema is reached by percussion, the sound will be 
hyper-resonant. 

C. Bronchitis of Smaller Tubes. — In mild cases 
slight dullness in percussion may be present over lower 
portion of lung. In severe cases, over that portion of 
chest which is in a. state of more or less compensatory 
emphysema there is a varying degree of hyper-reso- 
nance, while over the lower portion, when there is in- 
spiratory dyspnoea, imperfect expansion, collection of 
secretion in bronchioles and alveoli, with partial col- 
lapse of the lung, there is dullness, with slight tym- 
panitic quality. When the dyspnoea is expiratory, with 
distension of the alveoli, there is hyper-resonance. 

D. Bronchitis Involving Bronchioles and Alveoli. — 
Over areas of secondary bronchial pneumonia, if near 
the surface and of sufficient size, the percussion is dull 
in proportion to the extent of consolidation. As sur- 
rounding vesicles are frequently in a state of collapse 
the note may be dull, with tympanitic quality. When 
the consolidated area is small and overlapped by dis- 
tended emphysematous lobules percussion may give a 
tympanitic or hyper-resonant note associated with feeble 
breathing. (Pigs. 19 and 20.) 

Auscultation. — A. Bronchitis of Large Tubes. — In 
mild cases there is no change in normal breath sounds. 
In the more severe types of the disease, during the dry 
stage, the normal tubular sound heard over the trachea 



DIXEAHEH OF RESPIRATORY TRACT. 157 

and large bronchi lias a harsher quality, due to the 
slight narrowing of the tubes. When secretion is 
present, if tenacious, it may produce local narrowing, 
causing coarse sonorous rales. If the secretion is more 
liquid, a few large moist or mucous rales, which are 
easily removed by coughing, may be present In the 
adult marked auscultatory signs are the exception; m 
children they are present more frequently. Vocal re- 
sonance is unchanged. 

B. Bronchitis of Medium-sized Tubes.— In mild 
cases the breath sounds over the lung are normal, except 
that during the dry stage the quality is slightly harsher 
and the expiratory part of the sound is longer, but un- 
changed in quality and pitch. When the amount of 
fluid present in the tubes is fairly abundant, large and 
medium-size liquid, bubbling rales are heard during 
both inspiration and expiration. In more severe cases, 
when the lumen of the bronchi is narrowed by the con- 
gested and swollen mucous membrane during the dry 
stage, the respiratory murmur is less intense than nor- 
mal during inspiration, while in expiration it is pro- 
longed and has a faintly sonorous quality, which may 
be mistaken for a type of bronchial breathing, from 
which it is differentiated by being heard over both lungs 
and by the absence of the associated signs of consolida- 
tion, dullness and increased vocal fremitus. When the 
fluid is abundant and tenacious, sonorous and sibilant 
rales and rhonchi are present. These adventitious 
sounds may mask the respiratory murmur; they are apt 
to be inconstant, are easily changed in character by 
coughing and deep breathing, and are heard over both 
lungs with equal intensity. When the secretion is more 
liquid, dry rales are less prominent, and heard chiefly 
over the upper portion of the lung, while large and 
medium-sized liquid, bubbling rales predominate. They 
are nust abundant at the base, as the secretion tends to 
gravitate to the most dependent portion of the lung, 
especially in children and feeble adults. As the smaller 



158 THE RESPIRATORY SYSTEM. 

tubes become involved, either by extension of the inflam- 
mation or by gravitation of the secretions into them, 
the dry rales become more sibilant and the moist rales 
finer and more crepitating. Vocal resonance is normal 
or slightly diminished. 

0. Bronchitis of the Smaller Tubes. — The respiratory 
murmur may show very little change during the dry 
stage; the intensity of inspiratory sound is diminished, 
the quality being somewhat harsher and dry, the pitch 
unchanged. The expiratory sound is more intense than 
that of inspiration; the sound is prolonged, and may 
have a harsher, blowing quality. When liquid is 
present, sibilant rales and smaller mucous rales accom- 
pany both sounds. In direct proportion to the severity 
of the case the respiratory sounds are diminished in 
intensity and may be obscured and replaced by hissing, 
sibilant rales and small liquid rales and crepitations. 
As the secretion accumulates in the bronchi it tends to 
gravitate to the lower part of the lung, so that over this 
portion the small, bubbling and crepitating rales will be 
most marked, while over the upper portion of the lung 
the moist rales will be coarser and the sibilant rales 
more abundant. 

D. Bronchitis Involving the Lobular Bronchioles and 
Alveoli. — Extension of inflammation into the lobular 
bronchioles and alveoli (broncho-pneumonia) is shown 
by the more or less intense bronchial quality of the 
breath sounds, especially marked during expiration, or 
the breathing may be diminished; the rales heard over 
the areas of bronchial breathing are finer, more ringing 
or crepitating than those heard in simple bronchitis, and 
are most abundant just at the end of inspiration. Vocal 
resonance is increased over areas of consolidation. 

Differential Diagnosis. — The diagnostic features of the 
different varieties of acute bronchitis are: (1) There 
is a bilateral distribution of all the physical signs. (2) 
In proportion to the severity of the disease the smaller 
bronchi become involved, giving more marked physical 



DISEASES OF RESPIRATORY TRACT. 159 

signs over the lower portion of the chest. (3) The 
physical signs detected are those dne to changes in the 
bronchial tnbes only, i. e., the presence of rales of vary- 
ing size and interference with the movement of tidal air. 

The diseases with which acute bronchitis is most 
liable to be confounded are : 

Broncho-Pneumonia (Acute Catarrhal Pneumonia). — In 
both diseases the signs are bilateral, most intense at 
the base of the lung, and there are numerous rales, but 
in broncho-pneumonia there is not the same uniformity 
of distribution. Broncho-pneumonia gives, over the 
area of consolidation, increased vocal fremitus ; uncom- 
plicated acute bronchitis, normal or diminished vocal 
fremitus. Broncho-pneumonia, dullness of varying de- 
gree, according to amount of lung involved, bronchitis, 
but slight change in resonance. Broncho-pneumonia, 
bronchial or tubular quality of the breath sounds, which 
is absent in bronchitis. 

Acute Diffuse Pulmonary Tuberculosis. — The physical 
signs in this disease are bilateral, and at the beginning 
are almost identical with those of capillary bronchitis 
with small areas of broncho-pneumonia, but the general 
constitutional symptoms are graver. As the disease 
advances the physical signs become more distinctive. 

Inspection. — Tuberculosis : Respirations are more 
rapid, cyanosis out of proportion to dyspnoea, restricted 
motion over the entire chest, retraction of the thorax 
most marked over upper portion of lung and more 
marked at one apex than the other. Bronchitis : He- 
traction most marked over the lower lobes, generally in- 
creased fullness of upper portion of the chest in propor- 
tion to the retraction at base. 

Palpation. — Tuberculosis: Vocal fremitus may at 
first be diminished ; later increased with extension of 
consolidation. Simple bronchitis: Vocal fremitus 
normal or slightly diminished. 

Percussion. — Tuberculosis: Resonance early im- 
paired, with slight dullness due to change in the alveoli 



160 THE RESPIRATORY SYSTEM. 

and early pleuritic involvement. Dullness is most 
marked over the upper portion of the chest; there is 
increased sense of resistance over the part involved. 
Bronchitis : Percussion normal or hyper-resonant 

Auscultation. — The differential diagnosis rests 
chiefly on the course of the disease and the distribution 
of the rales. While in acute bronchitis, with the 
dyspnoea and cyanosis, there is a corresponding number 
of dry and moist rales, most marked at the base, in 
tuberculosis the number of moist rales is comparatively 
few, and they are as numerous, or even more so, at the 
apex as at the base ; also there is generally an uneven dis- 
tribution of the rales on the two sides. Later there is a 
tendency for the signs of consolidation to become more 
marked over different areas of the lung, and to be fol- 
lowed by signs of diffuse softening and cavity formation. 
Frequently it is possible to find in some portion of the 
lung, especially at the apex, an old focus, with its char- 
acteristic physical signs of long-standing consolidation. 

Pulmonary (Edema. — The differential diagnosis of 
bronchitis from pulmonary (edema rests chiefly on the 
order of occurrence of moist rales. In acute bronchitis 
the larger tubes are primarily involved, and the rales 
first detected are those of large size. With the exten- 
sion of the disease into smaller bronchi, rales of corre- 
sponding size are also present and are heard over the 
entire lung. In pulmonary oedema fluid collects in the 
alveoli, and fine crepitating rales are first heard over the 
lower borders and base of the lung. The larger rales are 
only present when the oedema is extensive. 

Chronic Bronchitis. 

The physical signs of chronic bronchitis, when only 
the mucous membrane is involved, are similar to those 
of the acute variety. Long continuance of the cough 
interferes with the function of the lung, and repeated 
attacks of acute or subacute bronchitis develop secondary 



DISEASES OF RESPIRATORY TRACT. 161 

changes in the bronchi, alveoli and pulmonary tissue. 
These changes determine the different types of chronic 
bronchitis and cause its symptoms and physical signs to 
be more or less characteristic of the secondary changes, 
(a) bronchiectasis, (b) asthma or spasmodic bronchitis, 
(c) emphysema, (d) fibroid or interstitial pneumonia. 
Types or Varieties of Chronic Bronchitis. — A. Simple 
chronic catarrh of the largo tubes (winter cough), 
characterized by cough and slight expectoration with 
tendency to intercurrent attacks of acute bronchitis. 
The structures of the lung are but slightly changed from 
the normal. 

B. Dry catarrh, characterized by very little secretion 
from the mucous membrane, by constant or persistent 
cough, scanty or difficult expectoration, presence of 
dyspnoea. The constant and violent attacks of coughing 
early induce emphysematous change, and acute attacks 
of bronchitis may cause it to assume temporarily the 
physical signs of the spasmodic type. The physical 
signs are those of acute bronchitis during the dry stage. 

C. Bronchitis with abundant secretion. Under 
this may be included (1) bronchorrhoea, of which two 
types are recognized, (a) cases in which the secretion is 
thin, watery, slightly tenacious, resembling the white 
of an unboiled egg. Severe paroxysmal attacks of 
coughing and dyspnoea occur in the morning and may 
last for one or two hours, after which the chest is clear ; 
or they may be repeated at longer or shorter intervals, 
followed by complete relief. From the character of the 
symptoms and expectoration the names mucoid 
asthma" and "bronchorrhoea serosa" have been given. 
(b) Cases with sero-purulent or mucopurulent expec- 
toration, attended with almost constant coughing and 
frequent attacks of paroxysmal dyspnoea. These attacks 
rapidly induce structural changes in the lung of the 
emphysematous, bronchiectatic and fibroid types. (2) 
Fetid bronchitis. In this form the secretions have 
undergone decomposition, and while it may occur in 

ii 



162 THE RESPIRATORY SYSTEM. 

bronchi that have not been dilated it is most frequently 
associated with dilatation of the bronchi and long reten- 
tion of secretion. (3) Plastic bronchitis, in which the 
secretion is coagulated in the bronchi occluding them by 
fibrinous 1 plugs. A still further subdivision of the types 
of chronic bronchitis has been made upon the secondary 
changes in the lung, as : D. Bronchitis with spasm of 
the bronchi, spasmodic or asthmatic bronchitis. E. 
Bronchitis with distension of the alveoli, emphysema- 
tous bronchitis. F. Bronchitis with marked fibroid 
or interstitial changes. 

Physical Signs. Inspection. — A. There is no change 
in the size, shape or movements of the chest. B. Thorax 
early assumes emphysematous type. Movements at first 
are exaggerated, and are more frequent. Later, expan- 
sion interfered with. Expiratory dyspnoea, C. In sim- 
ple serous bronchorrhoea the respiratory movements are 
similar to those of acute bronchitis ; in chronic purulent 
catarrh and simple putrid bronchitis, in the early stages, 
there is no change in Hie size or movements of the 
thorax. Later it assumes the emphysematous or fibroid 
type. Plastic bronchitis: extreme dyspnoea. Loss of 
expansion on inspiration especially marked over base of 
lung. When localized to small portion of bronchial 
tract, limited motion over affected area. D. Thorax 
gradually assumes more or less the condition found in 
emphysema ; the movements of the chest are similar to 
those present during an attack of spasmodic asthma. E. 
Chest emphysematous in all respects. F. General re- 
traction of the chest ; loss of expansion. 

Palpation. — A. Negative. B. Negative or vocal 
fremitus may be slightly diminished. C. Bronchor- 
rhoea, feeble vocal fremitus; rhonchi felt during acute 
paroxysmal attack. Plastic bronchitis, loss of vocal 
fremitus over occluded tubes. D. Vocal fremitus feeble,, 
rhonchi frequently present. E. Vocal fremitus feeble 
or absent. F. Increase of vocal fremitus especially 
marked over regions of large bronchi. 



DISEASES OF RESPIRATORY TRACT. 163 

Percussion. — Percussion note is unchanged in the 
milder types. When the lung has undergone emphy- 
sematous changes the note is hyper-resonant. Fibroid 
and cirrhotic changes give more or less dullness, with 
woodeny quality. 

Auscultation. — A. Signs indefinite. Few large 
moist rales may be detected, especially if secretion is 
present. Over the large bronchi the breath sounds may 
be slightly roughened in character. B. Dry catarrh 
respiratory murmur may be unchanged. ('. In (1) 
bronchorrhoea during the attach, large and small liquid 
rales and sibilant and sonorous rales may be present. 
Breath sounds obscured by loud noise of rales. After 
expulsion of mucus the respiratory murmur may be 
normal. (2) In fetid bronchitis the rales are more or 
less constant. Breath sounds are feeble. (3) In plastic 
bronchitis over that portion of the lung supplied by 
occluded bronchus there will be absence of all breath 
sounds. D. In spasmodic bronchitis, as the name im- 
plies, associated with the moist rales are the breath 
sounds and dry rales that characterize an acute 
asthmatic attack. E. In emphysematous bronchitis 
the breath sounds are feeble, especially the inspiratory 
sounds, the expiratory portion being prolonged, low 
pitched and usually attended with rales. F. In chronic 
bronchitis with fibroid change the inspiratory sound is 
feeble, but the expiratory portion is prolonged, high 
pitched and has a faint tubular character. 

Differential Diagnosis. — Chronic bronchitis is separated 
from the acute forms by the history of the attack and 
the presence of secondary changes in the lung. The 
various types of chronic bronchitis may be associated 
with pulmonary tuberculosis. 

BRONCHIECTASIS. 

Bronchiectasis is a distinct dilatation of the bronchial 
tubes. It may be limited to a portion of one lobe only, 



164 THE RESPIRATORY SYSTEM. 

or may involve to a greater or less extent the bronchi of 
one or both lungs. Bronchiectasis is never a primary 
disease, but is secondary to some pathological change in 
the walls of the bronchi which alters or destroys their 
elasticity. The dilating force may be (a) increased 
pressure within the tube caused by coughing, (b) trac- 
tion on the walls causing permanent enlargement of 
their calibre. This traction may be due to contraction 
of bands of fibrous tissue in the interlobular septa, 
especially when they are stretched from the bronchi out- 
ward to the pleura. The dilatation of the bronchi may 
be sacculated or cylindrical. 

The diseases with which bronchiectasis mav be asso- 
ciated as a complication are broncho-pneumonia, capil- 
lary bronchitis with atalectasis, chronic bronchitis 
affecting the large and medium-sized tubes, emphysema, 
obstruction of the tubes from pressure from without, 
interstitial change in the lung as occurs in chronic in- 
terstitial pneumonia (cirrhosis of the lung), in fibroid 
phthisis, and in pleurisy with retraction. 

Physical Signs. — The physical signs of bronchiec- 
tasis depend (1) upon the disease with which it is asso- 
ciated; (2) the nature of the dilatation, whether cylin- 
drical or fusiform; (3) whether the air passes through 
the dilatation to structures beyond; (4) the localization 
and distribution of the dilatations ; x ( 5 ) the proximity 
of the dilatation to the surface of the chest; (6) the size 
of the tubes involved; (7) the condition of the cavity, 
whether full or empty. 

Inspection. — The chest conformation of bron- 
chiectasis is not typical. The shape and size of the 
thorax are determined by that of the disease to which it 
is secondary or with which it is associated. Three types 
occur — the emphysematous, the retracted, and the com- 
binations of both where retraction in one portion of the 

1 One lung, 52 per cent. ; both lungs, 48 per cent. Of the uni- 
lateral cases the upper lobe was involved in 21 per cent. ; middle 
lobe, 3 per cent. ; lower lobe, 32 per cent., and the entire lung, 42 per 
cent. (Fowler.) 



DISEASES OF RESPIRATORY TRACT. 165 

chest is compensated for by emphysematous expansion at 
other portions. In the emphysematous type the upper 
portion of the chest, especially the supra- and infra- 
clavicular spaces, are markedly distended, while the 
lower portion shows more or less retraction. Motion 
over the affected area is restricted according to the type 
of the disease and the condition of the surrounding 
lung. In mild cases, and when the disease is localize* 1, 
motion may be but slightly impaired. When general or 
due to obstruction of the bronchi the affected side will 
be more or less retracted. 

Palpation. — Vocal fremitus varies with the condi- 
tion of the lung surrounding the bronchiectatic dilata- 
tion. When involvement of the bronchi is associated 
with emphysematous dilatation of the surrounding tis- 
sue vocal fremitus is normal or diminished. Vocal 
fremitus is absent in occlusion of the bronchi or filling 
of the cavities with secretion and also when marked 
pleural thickening has occurred. It is increased when 
the lung is fibrous and the bronchial tubes are patent 
bevond the dilatation. 

Percussion". — Percussion note varies with the extent 
of the lesion, the condition of the surrounding lung, the 
nearness of the dilatation to the surface and the quantity 
of secretion in the cavities. As many of these factors 
are subject to frequent change, variation in the degree 
of resonance is an important diagnostic sign. When 
dilatation of the bronchi is slight and it is surrounded 
by normal lung the percussion sound may be normal. 
When marked emphysematous dilatation with relaxa- 
tion of the lung occurs the sound will be hyper-resonant 
with a somewhat tympanitic quality added, due to the 
dilatation of the bronchi. When the dilatation of the 
bronchus is laro-e and near enough to the surface to be 
influenced by the percussion, the sound will be tympa- 
nitic or amphoric, according to the size. There will be 
change in the note according as the mouth is open or 
shut. When dilatation is surrounded by indurated lung 



166 TEE RESPIRATORY SYSTEM. 



the note is dull, high pitched, with peculiar tympanitic 
"boxy" or "boardy" quality. One of the distinctive 
features of the percussion sounds of bronchiectasis is the 
localization of the change to the middle or lower third of 
the chest, especially over the back. 

Auscultation. — The most important sign is a 
blowing, hollow, but not tubular, sound when the dilata- 
tion is cylindrical, and a cavernous sound when the dila- 
tation is sacculated. Both the inspiratory and expira- 
tory breath sounds are interrupted and wavy, the blow- 
ing or cavernous quality being most marked just at the 
end of inspiration (veiled puff). Moist rales are present 
according to the amount and distribution of secretion in 
the bronchi and cavity. When the dilatations are cylin- 
drical, the rales will have the characteristics of those 
heard in simple bronchitis of large and medium-sized 
tubes: But the size of the rales is larger than would be 
found if the tubes in that region were of normal calibre. 
In sacculated dilatation the rales are larger, more gurg- 
ling, with an occasional croaking, sonorous rale. When 
the dilatation is surrounded by fibrous lung the rales 
have a ringing or metallic quality. The occurrence of 
acute general bronchitis will change the character of the 
physical signs present over the cavity according as the 
bronchi are narrowed by inflammatory swelling or 
cavity filled with liquid secretion. With the subsidence 
of acute bronchitis, instead of the breath sounds return- 
ing to normal the characteristic sounds of dilatation are 
heard. Vocal resonance over the cavitv and whisnered 
cavernous or amphoric breath sounds may be heard, ac- 
cording to the size and condition of the cavity and the 
surrounding lung. 

Differential Diagnosis.— Bronchiectasis must be differ- 
entiated from other diseases of the lung in which cavity 
formation occurs. The character of the physical signs 
heard over the site of dilatation in bronchiectasis is not 
pathognomonic, and a diagnosis of the nature of the 
cavity can only be reached by exclusion. 



DISEASES OF RESPIRATORY TRACT. 107 

Pulmonary Tuberculosis. — Pulmonary tuberculosis is 
the most frequent cause of the cavities found in the 

lung. 

Location. — Non-tubercular, solitary hrouchiectatie 
cavities rarely involve the apices. It is most common 
at the base, but may involve the middle or lower third 
of the lung. Tuberculosis is especially likely to involve 
one or both apices primarily, extending to the middle 
and lower portions. In bronchiectasis the changes in 
the portion of the lung involved are more or less uni- 
form. In phthisis limited portions of the lung may 
show the different stages of the disease^. 

Inspection. — In bronchiectasis the retraction is most 
marked over the lower portion of chest; the upper por- 
tion may be normal or show in supra- and infraclavicu- 
lar spaces emphysematous dilatation. In tuberculosis 
the retraction is most marked in the upper portion of 
the lung; the supra- and infraclavicular spaces are de- 
pressed^ In bronchiectasis the patient is fairly well 
nourished and there is more or less duskiness of the 
skin, congestion of the mucous membrane, fullness about 
the lips and nose and the jugulars are distended. The 
tuberculous patient is emaciated, the mucous membrane 
and skin pale and anaemic and there is no distension 
of jugulars. In bronchiectasis the heart is displaced 
horizontally towards the diseased side: epigastric pulsa- 
tions are present. In tuberculosis the heart is displaced 
upwards and obliquely, and without epigastric pulsation 
except when it involves the base of the lung secondary 
to changes in the pleura. 

Palpation. — In bronchiectasis vocal fremitus may 
be diminished except when marked fibroid induration 
is the cause of the dilated bronchi. In tuberculosis 
vocal fremitus is generally increased in proportion to 
the amount of consolidated lung tissue around the 

cavity. 

Percussion. — Bronchiectasis : The supraclavicular 
region is rarely dull ; its note is generally hyper-reso- 



168 THE RESPIRATORY SYSTEM. 

nant or emphysematous. Dullness most frequently 
present over lower portion of chest. Tuberculosis: 
Dullness at the apex, becoming more intense as con- 
solidation advances. Cavernous, amphoric or cracked- 
pot percussion always follows a first stage of dullness. 

Auscultation. — Bronchiectasis : The blowing, hol- 
low sound of cylindrical dilatation and the cavernous 
tubular sound of the sacculated form are unattended by 
any signs of pulmonary consolidation. Normal breath- 
ing sounds may be heard between the areas of cavernous 
breathing. In tuberculosis the sound is cavernous or 
amphoric. Bronchial breathing is heard over surround- 
ing lung. In bronchiectasis the signs indicate that the 
cavities are of uniform size. In phthisis the cavities 
are rarely uniform. In bronchiectasis the size of the 
cavities remains nearly stationary. In phthisis the cavi- 
ties gradually enlarge, with associated signs of soft- 
ening. 

General Bronchitis and Fetid Bronchorrhoea. — Bronchiec- 
tasis is distinguished from general bronchitis by absence 
of fetor ; from simple fetid bronchitis and bronchorrhoea 
the differential diagnosis is often extremely difficult. 

The following signs are most important: hollow, 
blowing or cavernous or amphoric breath sounds, accord- 
ing to the type of cavity. In general bronchitis vesic- 
ular murmur is present, but diminished or feeble; 
cavernous breathing not present. The size of the rales 
has an important significance. In bronchiectasis over 
cavity there are large moist rales, mucous clicks and 
gurgles ; they are larger than could occur if the lumen 
of bronchi in that region was normal. In chronic bron- 
chitis the size of the rale corresponds to the normal size 
of the tube. 

Gangrene and Pulmonary Abscesses. — In pulmonary 
gangrene and pulmonary abscess there may be one or 
more cavities. When single, they generally follow some 
inflammatory condition of the lung or adjacent viscera. 
The signs of cavity formation are limited to a small 



DISEASES OF RESPIRATORY TRACT. 169 

portion of the lung, and are more likely to be close to the 
surface. The patient is acutely ill. Respirations are 
rapid and motion oyer affected area markedly interfered 
with. Pulse is rapid, feeble and dicrotic. Before the 
stage of excavation there is dullness on percussion, vocal 
fremitus is increased, there is bronchial breathing. 
With the production of the cavity, the hollow, blowing, 
cavernous or amphoric quality of breath sounds will be 
associated with the signs of more or less complete con- 
solidation. When the cavities are multiple they are 
nearer to the surface of the lung than in bronchiectasis 
and there is early involvement of the pleura over 

affected area. 

In bronchiectasis the patient is usually well nour- 
ished and does not give the impression of being acutely 
sick. The changes in respiratory movement are most 
marked over lower third of lung. 

Microscopical Examination. — Presence of elastic 
fibres in the sputum is diagnostic of the destructive 
process of gangrene and abscess and tuberculosis. They 
are absent in simple bronchiectasis. 

Localized Empyema Opening into a Bronchus. — Local- 
ized empyema opening into a bronchus, with localized 
pyo-pneumo-thorax, may simulate a bronchieetatie 
cavity, and is differentiated by the following: The 
enlargement of the chest is localized at the site of the 
lesion. The percussion note is tympanitic when cavity 
is empty. If it contains fluid, there will be zone 
of flatness, which changes with the position of the 
patient. Lung fistula sound is present rather than the 
hollow, blowing or cavernous sound of bronchiectasis. 

ACUTE CONGESTION OF THE LUNG. 

Active hyperemia of the lung may be general or local. 
It may depend on (a) cardiac overaction due to muscu- 
lar exertion, cardiac stimulants, nervous or emotional 
causes; (b) irirtation of the respiratory tract due to 
inhalation of steam, extremely cold air or other irri- 



170 THE RESPIRATORY SYSTEM. 

tants; (c) determination of blood to the lungs by chill- 
ing of the surface of the body or during the chill of 
acute diseases, especially malaria; (d) it occurs during 
onset of all inflammatory diseases of the lung. 

Physical Signs. —The physical signs will vary accord- 
ing to the degree of congestion. The distension of the 
blood-vessels is especially marked in the alveolar walls, 
causing the pulmonary tissue to be increased in amount 
and more rigid, with corresponding diminution in the 
amount of tidal and residual air. 

Inspection. — Dyspnoea, with respiration more rapid 
than normal. 

Palpation. — Vocal fremitus unaltered or slightly 
increased. 

Percussion. — Resonance slightly impaired, pitch 
somewhat raised but change in percussion note not suffi- 
cient to give well-marked dullness. 

Auscultation. — The respiratory murmur has less 
of the vesicular quality than normal ; inspiration is 
harsher and slightly higher pitched; expiration is pro- 
longed, higher pitched than inspiration, with a blowing 
quality. When the congestion is localized the above 
changes in the physical signs are more noticeable by 
comparison with the surrounding normal lung. 

PASSIVE CONGESTION OF THE LUNG. 

Passive hyperemia of the lung is caused by interfer- 
ence with pulmonary circulation due to (a) organic 
lesions at the valvular orifices or to pressure of inter- 
thoracic tumors, (b) to insufficiency of cardiac power, 
dependent upon myocardial disease or secondary to 
adynamic conditions, as typhoid fever, anaBmia, etc. 
Feebleness of respiratory movements favors stasis at 
the borders of the lung, while gravity causes the circula- 
tion to be weakest in the most dependent portions (hypo- 
static congestion), which varies with the posture of the 
patient. 

Long continuance of passive congestion causes exuda- 



DISEASES OF RESPIRATORY TRACT. 171 

tion of serum into (1) the interstitial tissue (hypostatic 
pneumonia), (2) into the alveoli, infundibula and bron- 
chi (pulmonary oedema), and (3) red-blood cells and 
connective tissue elements into the stroma of lung 
(brown induration). 

Physical Signs. Inspection. — Dyspnoea, respiratory 
movements most marked over upper portion of chest, 
loss of motion over base of lungs, slight cyanosis, espe- 
cially during sleep and on exertion. Patient gradually 
assumes the sitting posture. 

Palpation. — Vocal fremitus normal over upper por- 
tion of lung and diminished along edge of lung and over 
base in simple, passive congestion. When secondary 
changes (induration) occur vocal fremitus is increase* 1. 

Percussion. — Upper portion of chest normal or 
hyper-resonant, over base slight dullness, most marked 
over right side posteriorly below angle of scapula. 
Secondary changes in the lung causes the dullness to 
become more marked. 

Auscultation. — Over upper portion of chest the 
breath sounds may be normal or with inspiration 
harsher and expiration blowing and prolonged. Over 
the lower portion of the chest the vesicular murmur is 
feeble or absent. When induration occurs the breath 
sounds have a bronchial quality. Rales are present in 
oedema. 

In the early stage the physical signs are bilateral, 
later they become more intense over certain portions of 
the lung, according to the posture of the patient. 

PULMONARY (EDEMA. 

Pulmonary oedema is never a primary condition, but 
always secondary to (a) acute disturbance of pulmonary 
circulation, (b) acute inflammation of the lung, (c), 
passive congestion, (d) or is part of a general oedema. 
The oedema will be local or general according to the 
cause, and its distribution will be influenced by the same 
factors that were mentioned under passive congestion. 



172 TEE RESPIRATORY SYSTEM. 

Physical Signs. Inspection. — The change in size, 
shape and motion will depend upon the condition to 
which the oedema is secondary. Filling of the alveoli 
at the most dependent portion causes loss of motion, 
with compensation elsewhere. 

Palpation. — Vocal fremitus is diminished or absent 
over the lower portion of the chest. Bhonchi may be 
detected when fluid is present in the larger tubes. 

Percussion. — Dullness in the early stage over the 
base of the lung. As the air spaces become filled with 
fluid, dullness becomes more intense, and may be re- 
placed by flatness. The line of dullness gradually 
extends upward with increase in the amount of oedema. 

Auscultation. — The distinctive physical sign of 
pulmonary oedema is the presence of fine, crepitating, 
moist rales. In mild cases these are heard over the most 
dependent portions and along the borders, while over the 
rest of the lungs the breath sounds may be normal. As 
the oedema becomes more intense and involves the 
bronchi rales of larger size and more bubbling are also 
heard. 

LOBULAR PNEUMONIA. 

Synonyms. — Broncho-pneumonia, disseminated ca- 
tarrhal pneumonia, pulmonary catarrh. 

Lobular pneumonia is characterized by a filling of the 
alveoli by inflammatory products which differ from 
those of lobar pneumonia in containing less of the 
fibrin factors of the blood and more of the elements 
drawn from the lining membrane of the alveoli and 

bronchi. 

The pathological changes of lobular pneumonia may 
be due to a variety of causes: (a) Capillary bronchitis, 
(b) acute pulmonary catarrh of whooping cough and 
other infectious diseases, (c) passive or hypostatic con- 
gestion, (d) pulmonary infarction, (e) diffused tuber- 
cular infection. (See Pulmonary Tuberculosis.) 

The distribution of the areas affected by catarrhal 



DISEASES OE RESPIRATORY TRACT. 17 



Q 



pneumonia will vary according to the nature of the 
cause, and the type is determined by the physical signs. 
The affected lobules may be widely and fairly evenly 
scattered through both lungs, and separated by normal, 
emphysematous or collapsed lobules, giving (A) the dis- 
seminated typo of lobular pneumonia. Usually a 
number of adjacent lobules are involved, and produce 
well-marked patches of consolidation in different por- 
tions of the lung. (B) The confluent type is due to the 
coalescence of these patches, causing one or more lobes 
to be almost completely consolidated, producing a condi- 
tion which gives physical signs almost identical with 
those of lobar or croupous pneumonia. 

Physical Signs. A. Disseminated Lobular Pneumonia. 
— The physical signs of this form have been described 
under I). Acute Bronchitis. 

B. Confluent Lobular Pneumonia. — The physical signs 
differ from those of the disseminated type, as follows: 

Inspection. — Dyspnoea is more markedly obstructive 
during inspiration. As both lungs are not equally in- 
volved, deficient expansion is more marked over one side 
of the thorax. When due to passive or hypostatic con- 
gestion, loss of motion is most marked over the base or 
dependent portions. 

Palpation. — Vocal fremitus may be increased wlien 
the areas of consolidation are close to the surface. When 
they are separated from the surface by emphysematous 
lung or surrounded by collapsed lobules, vocal fremitus 
may be normal or diminished. 

Percussion. — In the early stage percussion may be 
normal. When surrounded by collapsed lung, the per- 
cussion note is dull, but of a tympanitic quality. With 
increase in consolidation, the resonance is diminished, 
the note becoming dull and high pitched. 

Auscultation. — The change in the breath sound will 
vary with the amount of pulmonary consolidation and 
its relation to the surface of the chest, When the con- 
solidated area is deep seated or surrounded by normal, 



174 THE RESPIRATORY SYSTEM. 

emphysematous or collapsed lung, the bronchial quality 
will not be heard, or it will be faintly detected only at 
the end of expiration (see Fig. 33). The nearer the 
pneumonic patch approaches the surface the more dis- 
tinctly will the bronchial breathing be heard. The 
rales heard over the consolidated part differ from those 
heard in bronchitis in being more uniform in size ; their 
number is fairly constant, and the quality is clearer, 
higher pitched and more definitely ringing, resembling 
the crepitant and subcrepitant rales of lobar pneumonia. 

Differential Diagnosis. Pulmonary Collapse (Atalectasis). 

Pulmonary collapse and lobular consolidation are 

both common in extensive bronchitis of the smaller 
tubes, and are usually associated. The physical signs 
will vary according as one or the other condition is pre- 
dominant. 

Inspection. — In both conditions motion is restricted, 
especially over the lower portion of the chest, ^ 

Palpation. — In consolidation vocal fremitus is nor- 
mal or slightly increased. In pulmonary collapse vocal 
fremitus is diminished or absent. 

Percussion. — In pulmonary consolidation the per- 
cussion note is dull. In pulmonary collapse there is 
diminished resonance, with tympanitic quality. 

Auscultation. — In consolidation the breath sounds 
are more or less bronchial in character ; in pulmonary 
collapse the breath sounds are feeble or absent. Vocal 
resonance, in consolidation increased ; in collapse, feeble 

or muffled. 

Acute Disseminated Tuberculosis. —Differential diag- 
nosis between acute disseminated tuberculosis with soft- 
ening and disseminated lobar pneumonia is extremely 
difficult. Physical signs may be identical, the location 
of the two conditions being frequently the only dis- 
tinctive point. Tuberculosis affects especially the 
apices, while lobular pneumonia involves the lower 
lobes, especially the base. 

Acute miliary tuberculosis without softening is dif- 



DISEASES OF RESPIRATORY TRACT. 175 

ferentiated from broncho-pneumonia in that it involves 
the apex, and rales are not common; broncho-pneumonia 
involves the base, and is attended with rales. 

Lobar Pneumonia. — Lobular pneumonia may be so 
extensive as to consolidate more or less completely an 
entire lobe. Lobular pneumonia, even when more or 
less lobar in character, does not present the uniform 
consolidation that occurs in lobar pneumonia, nor is it 
limited to one lobe or to one lung. In the second stage 
of lobar pneumonia over the affected portion of the lung 
the breath sounds are usually clear and unattended with 
rales. 

LOBAR PNEUMONIA. 

In lobar or croupous pneumonia the alveoli and 
smaller bronchi are filled with an exudate composed of 
coagulated fibrin and cellular elements. During the 
course of the disease the pathological changes pass 
through three definite stages. 

1. Stage of Engorgement. — The lungs are intensely 
congested, especially in the affected lobe, whose dis- 
tended blood-vessels interfere with its expansion and 
elasticity; the pulmonary tension is altered, and there 
is slight enlargement of the lobe. There is more or 
less liquid secretion in the alveoli and bronchioles and 
also oedema of the subpleural and pleural tissues. There 
may also be a layer of plastic material on the free sur- 
face of the pleura. This stage may last from a few 
hours to three or four days. 

2. Stage of Red Hepatization, or Consolidation. — In this 
stage there is distension of the alveoli and bronchioles, 
with serum, leucocytes and red-blood corpuscles. The 
serum coagulates and holds in its meshes of fibrilated 
fibrin the corpuscular elements. The consolidated por- 
tion is airless and "in a state of immovable expansion 
more densely solidified than it could be by anv artificial 
injection with coagulated fluid." (Powell.) 

The pleura over the consolidated portion is covered 



176 TEE RESPIRATORY SYSTEM. 

with a layer of the same coagulated exudate. In addi- 
tion the pleural sac may contain fluid serum, which may 
be clear, turbid, blood-stained or purulent. Complete 
consolidation of the affected lobe may occur in a few 
hours or, beginning in a circumscribed portion, it may 
be days before it extends throughout the entire lobe, or 
it may remain limited to a portion of the lobe only. 
This stage usually lasts from ve to seven days. 

3. Stage of Gray Hepatization, or Resolution. — The 
changes that take place during the stages of engorgement 
and consolidation are fairly constant and rapid. Those 
that occur during the third stage may be variable. At 
the beginning of the stage of grav hepatization the bulk 
of the lung is greater than in that of red hepatization, 
but it is less firm. The solid coagulum in the alveoli 
undergoes liquefaction; air again enters the alveoli, 
passing through the liquid exudate it gives rise to large 
moist rales that are named rale redux. 

The third stage of pneumonia may terminate in (a) 
resolution. The contents of the alveoli are removed by 
absorption and expectoration, the lung regains its re- 
siliency and returns to normal condition. In the 
majority of cases perfect resolution and recovery occurs. 

(b) Purulent Infiltration and Abscess of the Lung.— 
In this condition the coagulated fibrin liquefies, but 
instead of fatty degeneration and absorption of the cor- 
puscular elements a suppurative inflammatory process 
continues, there is destruction of the lung tissue and the 
formation of cavities of varying sizes. 

(c) Gangrene results from failure of nutritive circu- 
lation either through thrombosis of the large vessels or 
capillary stasis, 

(d) Unresolved or Chronic Pneumonia. — In this con- 
dition the changes that ordinarily occur with the crisis 
are absent. There is a proliferation of new cells in the 
tissues of the lung and also in the alveoli. These organ- 
ize into new tissue and there is a gradual development 
of fibrous tissue in the alveoli. 



DISEASES OF RESPIRATORY TRACT. 177 

Physical Signs.— The physical signs of pneumonia have 
been divided into three stages corresponding to the 
pathological changes in the lung. It must be constantly 
borne in mind that these pathological divisions are 
largely arbitrary and that, as the transition of one stage 
into the other may be rapid or gradual, so the physical 
signs of one stage merge into those of the succeeding 
stage. 

Inspection. — First Stage. Patient lies on the 
affected side, circumscribed flush (pneumonic spot) 
over one or both malar bones, respiration rapid, 25 to 
40, panting in character, especially during expiration. 
Motion on affected side slightly restricted. When the 
pleura is not involved the movements of the two sides 
may be equal. When pain (pleurisy) is present 
motion is less on the affected side than on the opposite, 
inspiration is either catching or restrained, expiration is 
slow. Movements of the opposite side are exaggerated. 

Second Stage. Face dusky, marked movements of 
the nares, breathing rapid and panting. Slight enlarge- 
ment of the affected side of the chest. Motion on the 
affected side diminished, with compensatory movement 
on the opposite side. Breathing will be costal or 
abdominal according as the upper or lower lobes are 
involved. Involvement of the diaphragm (diaphrag- 
matic pleurisy) causes absence of abdominal breathing. 

Third Stage. With the absorption of the exudate 
movements of the affected side gradually return to 
normal. 

Palpation. — First Stage. During the early stage 
of engorgement vocal fremitus is normal or slightly 
diminished. As consolidation occurs it gradually 
increases in intensity. 

Second Stage. When consolidation of the lung is 
complete, vocal fremitus is greatly increased. In cen- 
tral pneumonia vocal fremitus may be but slightly 
increased. It is diminished in marked thickening of 
the pleura, and absent when effusion occurs in the 
12 



178 THE RESPIRATORY SYSTEM. 

pleural sac, and also when the large bronchi leading 
to consolidated portion are blocked. Friction fremitus 
may be felt over the affected part in the earlier stages of 
consolidation while movement of the lung is still possi- 
ble. 

Third Stage. There is gradual diminution of vocal 
fremitus with return to the normal. During the early 
stage of resolution, blocking of the bronchus is most 
likely to occur, with a temporary absence of vocal 
fremitus. After paroxysms of coughing vocal fremitus 
may return. Absence of vocal fremitus after the re- 
moval of exudate from the alveoli is due to exudation 
on the pleura or filling of the pleural sac. 

Percussion. — First Stage. Percussion note at first 
may show no change. As congestion increases there is a 
circumscribed area or impaired resonance, the intensity 
diminishes, it is shorter in duration, higher pitched, 
but with a slight tympanitic quality. The dullness of 
consolidation is most apt to appear first just beneath 
the angle of the scapula and to develop towards the 
axillary line. As air in the alveoli is replaced by the 
solid exudate the note becomes duller, higher pitched 
and less resonant until complete consolidation. 

Second Stage. The percussion note is dull and high 
pitched, but even in complete consolidation resonance is 
present in a very slight degree. The sound is flat if 
pneumonia is complicated by extensive pleuritic 

changes. 

When consolidation is not complete the air-containing 
but relaxed lobules scattered through the consolidated 
portion cause the percussion note to have a dull, tym- 
panitic or tubular quality. When the pneumonia is 
central and air-contain in g lung is interposed between 
the chest wall and the consolidated portion, the charac- 
ter of the percussion note will depend upon the condi- 
tion of the interposed lung, (a) When the lung is in 
a state of compensatory emphysema and tension is in- 
creased, the percussion note gives increased resonance. 



DISEASES OF RESPIRATORY TRACT. 179 

(b) When the lung is relaxed the percussion note is 
dull, with tympanitic or cavernous quality. Dullness 
is especially apt to be absent in children and in old 
persons, due to the elasticity of the chest wall in children 
and the emphysematous condition of the lung, associated 
Avith rigid thorax in the aged. 

The normal boundaries of the lobes are changed, so 
that when the lower lobe is involved the dullness extends 
higher than the normal outline, and may be detected 
almost to the upper portion of the scapula. When the 
entire lower lobe is consolidated dullness is present over 
the whole posterior portion of the thorax, except above 
the spine of the scapula, where the relaxed upper lobe 
gives a tympanitic sound. The extension upward pos- 
teriorly of the line of dullness beyond the normal limits 
of the lower lobe frequently leads to the erroneous 
diagnosis of involvement of the upper lobe also. When 
the upper lobe is involved the dullness is most marked 
anteriorly. Enlargement of the consolidated portion 
allows of relaxation of the unaffected portions of the 
lung on the same side, over which a peculiar tympanitic 
resonance is obtained — Skoda's resonance. This is most 
marked over the upper anterior portion of the chest 
when the lower lobe is completely consolidated. Per- 
cussion over the opposite lung shows exaggerated per- 
cussion note, due to compensatory emphysema. 

Third Stage. As the removal of the exudate con- 
tinues and the alveoli again contain air, the percussion 
sound becomes more resonant. The pulmonary tissue 
does not at once regain its normal elasticity, and fre- 
quently with the return of resonance the sound has a 
more or less tympanitic quality and is low pitched, on 
account of the relaxation of the lung. Dullness may 
be continued after resolution is well advanced, owing to 
the presence of pleural exudate. Flatness over the base 
of the lung occurs in cases of unabsorbed effusion in the 
pleura or the occurrence of empyema. It was noted 
above that lobar pneumonia in children is frequently 



180 THE RESPIRATORY SYSTEM. 

unattended with marked dullness. The presence of 
well-marked dullness, with increased resistance over the 
lower portion of the lung, is usually due to the occur- 
rence of acute empyemia during the course of a pneu- 
monia. 

Auscultation.— i^tf #%e. In the earliest stage 
of engorgement the breath sounds are weaker than 
normal over the affected portion, while over adjacent 
portions the breath sounds are slightly exaggerated or 
puerile. Later, as the engorgement increases, the breath 
sounds become harsher, especially marked during expi- 
ration As the exudation fills the alveoli the inspiratory 
portion of the breath sound loses its vesicular element, 
has a faint blowing quality, and the pitch becomes 
higher The expiratory portion is at first slightly pro- 
longed, higher pitched, with a distinct bronchial charac- 
ter As the consolidation becomes more marked there 
is a gradual disappearance of the normal vesicular 
murmur and an increase in the intensity of the bronchial 

breathing. . , 

The crepitant rales (rale indux), which has been 
considered by some authors as characteristic oi this 
stage of pneumonia, may be present before percussion 
dullness or the occurrence of the bronchial type oi 
breathing. The crepitant rale is not always present. It 
may be absent (a) when the consolidation is central 
and there is no pleural involvement, (b) when complete 
consolidation occurs very rapidly, (c) in secondary 
pneumonia. When pneumonia is superadded to acute 
bronchitis, large and small moist rales may be present 
and mask the crepitant rale and the early changes m the 
breath sounds. The crepitant rale, when present, is of 
important diagnostic significance. 

Second Stage. Bronchial breathing during the 
second stage is present in proportion to .the degree of 
consolidation. As the alveoli becomes filled the breath- 
ing passes from a stage of high-pitched, prolonged 
expiration (broncho-vesicular), to pure tubular and 



DISEASES OF RESPIRATORY TRACT. 181 

laryngeal breathing. The bronchial, tubular and 
tracheal breathing that is present in pneumonia differs 
from that heard over the bronchi, trachea and larynx in 
the normal lung. It is higher pitched, expiration is 
more prolonged, and the tubular element lias a peculiar, 
distinct, "audible" quality, which is a striking feature 
of the sound. Although it may not bo very loud, this 
quality of the sound is easily detected when present. 
This distinctive quality of the breath sound in pneu- 
monia is due to the resonating influence of the dense 
consolidated lung on the vibrations brought to it by the 
walls of the bronchi. In central pneumonia the inter- 
posed unconsolidated lung causes the breath Bounds to 
have a distinct bronchial element, associated with nor- 
mal vesicular murmur. The bronchial element in thea 
cases is especially marked during expiration. When 
the amount of consolidation is slight and situated deep 
in the lung, the bronchial sound may not be detected as 
such, but a high-pitched blowing sound may be heard 
after the expiratory sound of the normal lung has 
ceased. In cases of central pneumonia, increased vocal 
resonance (bronchophony) may be the only sign present. 
In the aged (senile pneumonia) bronchial breathing is 
frequently absent during the entire course of the disease, 
being replaced over the affected area by weak breath 
sounds associated with tympanitic percussion note. 
Plugging of a large bronchus causes the bronchial 
breathing to be absent; this is especially apt to occur 
in the massive type of pneumonia. Thick exudation 
upon the pleura or effusions into the pleural cavity 
gives a weakening or absence of the bronchial sounds. 
Effusions into the pleural cavity, especially when they 
occur before the stage of complete consolidation, give 
a type of breathing that is similar to cavernous breath- 
ing. In pneumonia affecting the upper lobes of the 
lung, feebleness or absence of bronchial breathing may 
occur without blocking of the bronchus or the inter- 
ference of thick pleural exudate. Over the unaffected 



182 THE RESPIRATORY SYSTEM. 

portion of the same side the respiratory sounds may be 
feeble or exaggerated, according as the lung is relaxed 
or is in a state of compensatory emphysema. Over the 
opposite lung the breath sounds are exaggerated. Fre- 
quently bronchial sounds may be transmitted to the 
opposite side, suggesting the occurrence of double pneu- 
monia. 

Vocal resonance is increased in intensity in propor- 
tion to the degree of consolidation, and corresponds to 
the various changes that occur in the bronchial breath- 
ing. Pectoriloquy is present in complete consolidation. 
In central pneumonia, when uninvolved overlying lung 
masks the physical signs, increase in vocal resonance 
may be the only diagnostic symptom present; it should 
always be sought for in doubtful cases, especially in the 

aged. 

Third Stage. The earliest indication of change in 
the consolidated lung is that the peculiar, clear, "audi- 
ble" character of the bronchial breathing of the 
second stage is lost. The breath sounds become bron- 
chial and their vibratory quality gradually disappears. 
With these changes in the bronchial sounds, air again 
enters the bronchioles and alveoli, and medium-sized 
rales (rale redux) are heard with inspiration and ex- 
piration. As the alveoli become; free of the exudate: the 
moist rales diminish in number and finally disappear. 
The vesicular quality returns as the bronchial is lost. 

As the lung does, not at once regain its normal 
elasticity, the expiratory sound may for a variable time 
be slightly prolonged and low pitched. In chronic un- 
resolved pneumonia the signs of the secondary stage 
persist for a long time, and are gradually replaced by 
those of chronic interstitial pneumonia. When the 
pneumonic area undergoes purulent infiltration the 
rale redux is associated with or displaced by larger 
liquid rales, the bronchial element of sound persists, 
and later, with the destruction of lung tissue, cavernous 
breath sounds are present. 



DISEASES OF RESPIRATORY TRACT. 183 

Vocal Resonance.— With the beginning of the third 
stag©, pectoriloquy of the second stage is replaced by 
bronchophony, which gradually diminishes in intensity 
until it becomes exaggerated resonance. With the com- 
pletion of resolution the voice sounds return to the 

normal. 

Differential Diagnosis. Acute Pulmonary Congestion.— 
During the early part of the first stage of pneumonia 
the harsh respiratory murmur over the lung is due to 
acute congestion of the entire respiratory tract. As the 
localization of the congestion occurs in the lobe that is 
to be affected there will be a gradual increase in the 
harshness of the respiratory murmur in comparison 
with the rest of the lung. 

Pleurisy with Effusion. — During the stages of consoli- 
dation and resolution, pneumonia may be confounded 
with effusion into the pleural cavity. It is especially 
important that these two conditions be differentiated, 
on account of the frequency with which empyema fol- 
lows pneumonia, especially in children. 

Inspection. — In pneumonia the size of the chest is 
only slightly increased; the intercostal spaces persist. 
not being flattened or bulged; motion of the affected 
side, is limited ; of the opposite, slightly increased. In 
effusion into the pleura the enlargement of the affected 
side is marked; there is flattening or bulging of the 
intercostal spaces. The motion over lower portion of 
the chest is absent, Position of the heart: In pneu- 
monia the apex beat is in a normal position. In 
effusions into the pleura the heart is displaced. Loca- 
tion of the apex beat of the heart is one of the most 
important signs in separating the two conditions. 

Paepation. — In pneumonia the vocal fremitus is 
markedly increased, except when the bronchus is 
plugged or the consolidated area is central. In effusion 
vocal fremitus is absent, or is only detected when 
adhesions are present. In pneumonia the diaphragm 
is not displaced downwards, and there is no change 



184 THE RESPIRATORY SYSTEM. 

in the position of the abdominal organs. In effusion 
there is marked displacement of the diaphragm; the 
liver or spleen are palpable below the free border of 

the ribs. 

Percussion. — In pneumonia the note is dull, but 
still resonant, it is not flat ; in effusion the note is flat or 
toneless. In pneumonia the area of percussion dullness 
follows the anatomical division of the lung. In effusion 
it follows a curved line, being highest in the axilla. 
Skoda's resonance may be present in both conditions. 

Auscultation. — In pneumonia the breath sounds 
over area of dullness are bronchial or tubular in char- 
acter. The sound gives the impression of being pro- 
duced close to the surface. In effusion the breath 
sounds are absent over the lower portion of flatness; 
bronchial breathing may be present at the upper level of 
the fluid, and differs from that of pneumonia in lacking 
clearness and being more or less distant from the sur- 
face. In pneumonia during the stage of resolution rales 
are present, In effusion liquid rales are not detected ; 
friction rales may occasionally be heard. 

Vocal Resonance. — In pneumonia, bronchophony ^ or 
pectoriloquy is present. In effusion over lower portion 
of thorax, the voice sounds distant from the ear; oyer 
the upper portion of the fluid pectoriloquy of a peculiar 
nasal character is heard (segophony). 

Hemorrhagic Infarction. — In hemorrhagic infarction 
the consolidation of the lung is due to the presence in 
the alveoli of the affected area of coagulated blood, so 
that the physical condition of that portion of the lung 
involved by the hemorrhage infarcts is identical with 
that of a localized lobar pneumonia. Differential diag- 
nosis is based on the position and distribution of the 
consolidation and the presence of valvular disease of the 
heart. In pneumonia the entire lobe # is usually 
involved. Hemorrhagic infarction is localized, and is 
most apt to occur at the lower portion of a lobe and 
along its border. In pneumonia, unless complicated 



DISEASES OF RESPIRATORY TRACT. 185 

by organic cardiac disease, there are no adventitious 
heart sounds. Hemorrhagic infarction is generally asso- 
ciated with the physical signs of valvular lesion of 
the heart The dyspnoea in pneumonia is panting; the 
patient lies upon the affected side or more or less flat 
upon the back. In hemorrhagic infarction the patient 
assumes the position of orthopnea during the early por- 
tion of the attack. 

Collapse of the Lung.— When this condition occurs in 
children, or when it affects an entire lobe, differential 
diagnosis may be very difficult On inspection, in 
pneumonia, there is slight enlargement of the side; in 
collapse, retraction of the side occurs. In pneumonia 
there is increased vocal fremitus; in collapse, fremitus 
is diminished or absent. 

In pneumonia there is dullness on percussion; in 
collapse the resonance is slightly impaired and asso- 
ciated with marked tympanitic quality. 

In pneumonia there is well-defined bronchial breath- 
ing; in collapse the breath sounds are feeble, may 
have slight bronchial character, but are indistinct and 
distant from the ear. Pneumonia, during first and 
third stages rales are present; in collapse these signs 
may be absent. 

CHRONIC INTERSTITIAL PNEUMONIA. 

Synonyms. — Cirrhosis of the lung. Fibroid phthisis. 

The distinctive pathological change in this type of 
pulmonary disease is the increase in the fibrous struct- 
ures of the lung. This overgrowth of connective tissue 
may be limited'to the peribronchial tissue of the larger 
or medium-sized tubes. It may affect the interlobular 
septa, extending into the interlobular wall. In other 
cases it primarily involves the walls of the alveoli 
themselves, while in others it starts in the snbpleural 
and pleural tissues and gradually extends inwards. It 
is rare to find fibroid induration limited to the different 
tracts above mentioned, although it may have its origin 
in one or the other of them. 



186 THE RESPIRATORY SYSTEM. 

The effect of increase of fibrous tissue is (a) to 
increase the solid structures of the lung, (&) Accord- 
ing to the law of fibrous tissue, contraction takes place, 
(c) The induration of the tissue and the thickening of 
the walls of the alveoli interfere with the elasticity of 
the lung, and causes more or less impairment of the pul- 
monary function, (d) Following the contraction, there 
is more or less atrophy of the alveolar walls, resulting 
in emphysematous dilatation or disappearance of the 
walls, and coalescence of adjacent alveoli, (e) Bron- 
chiectasis of varying degree is also present. 

Three types of pulmonary fibrosis can be recognized 
by physical signs: (1) The massive or lobar type ; 
(2) the broncho-pneumonic type ; (3) the disseminated, 
reticular or diffuse type. The type of the disease 
corresponds more or less closely to the etiological factors. 

(1) Lobular pneumonia and the confluent type of 
broncho-pneumonia with collapse are often the origin 
of the massive or lobar type. Pleurisy with effusion, 
in which there has been extensive changes in the pul- 
monary subpleural tissue and long retention of fluid in 
the sac, causing more or less pulmonary collapse, is 
frequently followed by a lobar type, in which the 
primary changes are at the; surface of the lung, crippling 
its respiratory function, and followed by retention of 
secretion within the alveoli, secondary broncho-pneu- 
monia, and subsequent diffuse fibrosis. The occlusion 
of a large bronchus by foreign bodies or by pressure, 
as of aneurism, causes"the tissue beyond the obstruction 
to collapse more or less. There is retention of inflam- 
matory exudates, and the subsequent development of 

fibroid tissue. 

(2) The broncho-pneumonic type may be induced by 
those conditions which cause diffuse capillary bronchitis 
or broncho-pneumonia. The broncho-pneumonic type, 
when localized at the apices, is especially prone to occur 
as a part of the pathology of pulmonary tuberculosis, 
and is to a large extent a conservative process. It may 



DISEASES OF RESPIBATOKj TRACT. 187 

occur either at the beginning of the disease, may follow 
on acute secondary inflammation or may be cicatricial 
when there lias been cavity formation. 

(3) The disseminated type is generally dependenl 
upon chronic bronchial irritation which may follow 
simple bronchitis, or may be due to the mechanical 
irritation in the so-called dust disease, or pneumonoko- 
niosis. Two forms of diffuse fibrosis arc recognized by 
physical signs: 1. The emphysematous form, in which 
the fibroid tissue of the peribronchial and interlobular 
portions of the lung are especially involved and there is 
associated dilatation of the alveoli. 2. The contracted 
form, in which the alveolar walls and the subpleural 
tissue are especially involved. In this there is marked 
loss of the expansile tissue of the lung. 

Physical Signs. Inspection. — In the localized fibro- 
sis of the lobar and hroncho-pneumonic types there is 
marked retraction of the chest over the seal, of the dis- 
ease, the extent being in proportion to the amount of 
lung tissue involved." Retraction of the lung causes a 
flattening of the chest wall, raising of the diaphragm 
and displacement of the mediastinum and heart toward 
the affected side. Change in the position of the ribs 
causes depression of the shoulder and curvature of the 
spine. The respiratory movements over the affected 
area are restricted in proportion to the extent of the 
disease. The opposite side will be in a state of com- 
pensatory emphysema and functional activity. 

In the emphysematous form the shape and size of the 
chest and the respiratory movements will correspond to 
those described under Large-Lung Emphysema (see 
Emphysema). In the contracted form the shape of the 
chest is more or less analogous to the small lung or 
senile form of emphysema. There is contraction of the 
lower portion of the thorax; the intercostal spaces are 
narrowed ; the ribs may overlap. Expansion of the lung 
is deficient; the diaphragm is carried upward, and the 
supraclavicular and suprasternal spaces are deepened. 



188 THE RESPIRATORY SYSTEM. 

It is rare for this condition to be uniform or equally 
marked on both sides. In tuberculosis one entire lung 
may be involved, while in the other it may be limited to 
the apex. When secondary to mechanical bronchitis 
the changes are more uniform. 

Palpation. — Vocal fremitus is variable, and gives 
important information as to the nature of the change in 
the lung and the extent of the involvement. In the 
massive or lobar type there will be increase in vocal 
fremitus. In the broncho-pneumonic type the change 
in vocal fremitus will correspond to the extent of the 
disease and its nearness to the surface of the lung. The 
vocal fremitus may be feeble or absent when there is 
obstruction of the bronchi leading to the affected area, 
and when there is marked thickening of the pleura. In 
the diffuse type vocal fremitus is markedly diminished 
in the emphysematous form. In the contracted format 
may be increased, but usually, on account of its associa- 
tion with pleural thickening, it is feeble or absent. The 
localization of the disease also causes variations in the 
intensity of the vocal fremitus. Fibrosis of the apex is 
usually attended with increased vocal fremitus, while 
when the base is involved the vocal fremitus is dimin- 
ished or absent. 

Percussion. — Increase of the solid structure of the 
lung causes dullness of the percussion note. Loss of 
tension of the lung and diminution in the size of the 
alveoli causes the dullness to have a peculiar wooden 
and tympanitic quality. Thickening of the pleura 
causes a more marked dullness, with increased sense of 
resistance. In the emphysematous form the increase 
in the size of the alveoli causes the percussion note to 
be hyper-resonant. 

Auscultation. — In the lobar type the breath sounds 
are bronchial in character and more or less weakened, 
but differ from those present in true lobar pneumonia 
in being less intense and having a somewhat soft, blow- 
ing quality. Bronchophony is also present, but is weak 
and distant. 



DISEASES OF RESPIRATORY TRACT. 189 

In the broncho-pneumonic type, if the area involved 
is close to the surface of the lung, bronchial or broncho- 
vesicular breathing will be present. When situated 
deeper in the lung and covered by distended alveoli,, 
bronchial breathing may be absent, and the respiratory 
murmur will be feeble. When rales are present over 
the affected areas they will have a sharp, metallic 
quality. In the disseminated type one of the character- 
istic features is the feebleness or absence of the vesicular 
element of the inspiratory sound, associated with feeble, 
prolonged and slightly" bronchial expiratory sound. 
Pleural changes cause both the vesicular and bronchial 
elements of the breath sounds to be weakened or 

obliterated. 

Differential Diagnosis. — The differential ion of the 
fibrosis that occurs in tuberculosis from that of non- 
tubercular diseases of the chest is frequently impossible. 
Fibrosis always occurs in certain forms of tubercular 
infection of the lung, and has no distinctive features. 
The condition known as coal miners' phthisis, fibroid 
phthisis, etc., is frequently duo to the combination of 
dust irritation and tubercular infection. Frequently 
the fibroid changes in the lung are so marked as to 
become the most "important factor, while the tubercular 
changes are subsidiary. 

EMPHYSEMA. 

Pulmonary vesicular emphysema is an overdistension 
of the air-vesicles, and may be acute or chronic. The 
varieties of emphysema are: (1) Compensatory or 
vicarious. This may be limited to a few lobules, to a 
lobe or involve one lung only. This type of emphysema 
occurs when distension of a portion of the pulmonary 
tract is compensatory for deficient expansion in other 
portions of the lung. 

(2) General vesicular emphysema. In this variety, 
associated with dilatation of the air-vesicles, are struct- 
ural changes in the walls of the alveoli which diminish 



190 THE RESPIRATORY SYSTEM. 

their resiliency and lead to atrophy. Two types of 
general emphysema are recognized: (a) Chronic, large 
lung or hypertrophic emphysema, and (b) small lung, 
atrophic or senile emphysema. 

(3) Interlobular or interstitial emphysema, with 
infiltration of air into the pulmonary stroma,. 

In general, chronic, large-lung emphysema the most 
marked change, in addition to increased dilatation of 
the alveoli, is a loss of elasticity of the alveolar walls, 
which influences the respiratory function. As has been 
mentioned before, while the pulmonary tissue is passive 
during inspiration, merely dilating with enlargement 
of the thorax, during expiration it is active, and plays 
a most important part in contracting the chest. Perfect 
respiration requires that the chest be contracted as well 
as expanded. The power of the lung to contract is due 
to (a) elasticity of the alveoli; (b) contraction of the 
muscular tissue of the bronchial tract. 

In proportion as the normal elasticity of the pul- 
monary tissue is impaired in emphysema, the following 
conditions are induced: (a) Faulty expiratory con- 
traction leads to gradual overdistension of the lungs, 
increase in the amount of residual aid and diminution 
in the amount of tidal air. The chest wall, unacted 
upon by the elasticity of the lung, assumes at first the 
position of full inspiratory expansion. As the ventila- 
tion of the lung is imperfect, dyspnoea is easily induced 
on exertion, and the accessory inspiratory muscles are 
called into play to increase still further the capacity of 
the chest. The upper portion of the bony thorax is 
carried upward; the sternum is carried forward; ribs 
rotated outwards; the intercostal spaces widen; antero- 
posterior diameter of the chest increases ; "enlargement 
of the chest to the limit of thoracic resiliency occurs." 
(Powell.) Enlargement of the lung displaces the heart 
towards the median line, and the diaphragm is de- 
pressed, together with the abdominal organs. 

(b) Circulatory changes. The circulatory system is 



DISEASES OF RESPIRATORY TRACT. 191 

affected in two ways: (1) Normally the elasticity of 
the lung causes a negative pressure within the thorax, 
which during inspiration equals 7 to 9 mm. of mercury. 
"The elastic fibres of the lung are upon the stretch and 
are pulling upon the ribs, intercostal spaces, upon the 
diaphragm and upon the heart and great vessels. The 
elastic pull of the lung . . . assists the diastolic 
expansion of the ventricles . . . and acts upon 
the vena cava within the chest and generates within 
them, as well as within the right auricle, a force of suc- 
tion. This suction from within the chest extends to the 
great veins just without it in the neck." 1 

As the elasticity of the pulmonary tissue becomes im- 
paired, the suction force of the lung decreases; there is 
a corresponding imperfect dilatation of the right auricle 
and emptying of the great veins. This interferes with 
the return circulation, which early shows itself in dis- 
tension of the jugular veins and a tendency to general 
venous stasis. 2 (2) The dilatation of the alveolar 
walls, with the subsequent atrophy, causes obstruction 
to the pulmonary circulation through narrowing the 
capillaries, by stretching and by obliteration. The 
effect of this circulatory obstruction is to raise the pres- 
sure in the pulmonary artery, which is early indicated 
by accentuation of the pulmonic second sound. To over- 
come the increased tension in the pulmonary artery, the 
right heart hypertrophies. Sooner or later the hyper- 
trophy fails to keep pace with the progressive obstruc- 
tion of the pulmonary circulation and the increased 
work; the right ventricle is unable to empty itself; 
dilatation of the cavity occurs, with incompetency of the 
tricuspid valve, and regurgitation in the right auricle. 
When tricuspid regurgitation occurs the imperfect 
venous return, due to diminished negative pressure, is 



i American Text-Book of Physiology, Vol. I, p. 95. 

"- In compensatory emphysema the decrease in negative pressure is 
not present. In the senile type it is not a marked feature of the 
disease. 



192 THE RESPIRATORY SYSTEM. 

acutely increased; pulsations occur in the jugular vein; 
there is passive congestion of all the abdominal viscera, 
with enlargement of the liver and spleen, the occurrence 
of ascites and general anasarca. 

Physical Signs.— The physical signs of _ emphysema 
vary with the degree of pulmonary distension and loss 
of elasticity. They are modified by intercurrent attacks 
of acute bronchitis, spasm of the bronchi (asthma) and 
the secondary changes in the circulatory system. 

Inspection. Large-Lung Emphysema. — The patient 
presents a more or less characteristic appearance. The 
chest is enlarged in all directions, especially in the 
anteroposterior diameter. The dorsal curve of the 
spine is exaggerated. The sternum is carried forward ; 
the ribs are rotated outward and are more horizontal; 
the upper intercostal spaces are widened, and the lower 
portion of the chest is seemingly contracted in com- 
parison with the upper portion, but there is an increase 
in the transverse diameter. These changes in the bony 
thorax give the barrel-shaped chest of emphysema. 
Mensuration shows enlargement of the thorax is in all 
directions, especially marked in anteroposterior 

diameter. 

The movements of the thorax are altered ; inspira- 
tion is short, jerky, with very slight expansion from first 
to fourth ribs. The muscles of the neck are hypertro- 
phied and prominent, the upper portion of the chest 
being pulled upwards by the accessory muscles of in- 
spiration, With inspiration the suprasternal, supra- 
clavicular and upper intercostal spaces are deepened. 
The lower portion of the chest is depressed during in- 
spiration by the action of the diaphragm, and breathing 
is chiefly abdominal. 

Expiration is tardy, slow and prolonged, with forcible 
contraction of the abdominal muscles. During expira- 
tion the intercostal spaces may be even with, or project 
beyond, the level of the ribs. Cardiac impulse is not 
seen in the normal site, but is displaced downward and 



DISEASES OF RESPIRATORY TRACT. 193 

inward. Epigastric pulsation is marked. The jugular 
veins are prominent and, in tricuspid regurgitation, 
pulsating. 

Smatt-Lung Emphysema. — The patient has the 
wasted, shrunken appearance of old age. The thorax is 
contracted, the shoulders are rounded, but the clavicles, 
ribs and sternum are depressed; the intercostal spac< - 
are narrowed below the fourth rib. The lower ribs are 
very oblique, and the edges may be in contact The 
movements of respiration are shallow ; the thorax is 
more rigid than in the large-lung type. During inspira- 
tion there is deepening of the supraclavicular fossa and 
intercostal spaces. The diaphragm is not depressed, 
but its descent is limited. Cardiac impulse is not dis- 
placed downward and toward the median line, as in the 
large-lung type, but may be slightly elevated and carried 
further to the left. Epigastric pulsation and distension 
of the jugular veins are absent. 

Compensator!) Emphysema* — When compensatory 
emphysema involves the entire lung, the enlargement of 
the side is attended with movements of increased func- 
tion, i. e., increased expansion during inspiration, while 
in expiration the contraction of the thorax is energetic 
and prolonged. The cardiac position varies Avith the 
cause of the emphysema and the side involved. 

Emphysema limited to a lobe or part of a lobe will 
affect the size, shape and movement of the thorax, ac- 
cording to the cause. When emphysematous dilatation 
occurs in portions of the lung surrounding areas of con- 
solidation or induration, it may prevent the deformity 
that is usually associated with the primary condition. 

Palpatiox. Large-Lang Emphysema. — Vocal frem- 
itus varies in proportion to the rarefaction of the lung 
and the diminution of pulmonary tension. It may be 
normal in mild cases, diminished or absent in well- 
marked. Cardiac impulse felt in the epigastric region 
is diffuse; the force depends entirely upon the degree 
of hypertrophy of the right ventricle. The liver may 
13 



194 THE RESPIRATORY SYSTEM. 

be felt below the free border of the ribs ; the edges are 
firm, smooth and rounded in proportion to the conges- 
tion from disturbed venous return in the vena cava, 
The spleen may be enlarged and palpable, secondary to 
hepatic congestion. When emphysema is associated 
with bronchitis or spasm of the bronchi, rhonchi may be 

felt. 

Small-Lung Emphysema. — Vocal fremitus is but* 
slightly changed, and may show slight increase in 
intensity, especially over the areas of large bronchi. 

Compensatory Emphysema. — Increased tension of 
the lung causes the normal vocal fremitus to be slightly 

increased. 

Percussiok. — Large-Lung Emphysema. — Raref ac- 
tion of pulmonary tissue and increased amount of air 
contained in the thorax causes the percussion note to be 
hyper-resonant; the low tension of the pulmonary tissue 
lowers the pitch. The condition of the chest wall (page 
90) permits the bony quality to be added to that of the 
pulmonary tissue, so that the quality is changed. Ac- 
cording as these different elements enter into the per- 
cussion sound, it has been described as vesico-tym- 
panitic, band-box, boardy, woodeny, etc. The character 
of the sound does not show variation during inspiration 
and expiration. The borders of the lung are extended, 
and resonance may be obtained as low as the twelfth 
rib behind. The normal areas of hepatic and cardiac 
dullness are diminished or absent. 

Small-Lung Emphysema. — The percussion note is 
hyper-resonant, but the pitch is not lowered ; the quality 
is clearer but less tympanitic than in the large-lung 
type. The areas of cardiac dullness are not diminished, 
but may be increased by retraction of the pulmonary 
borders. Hepatic dullness is slightly higher than nor- 
mal. The rigid chest wall gives an increased sense of 



L t3 

resistance. 



Compensatory Emphysema. — In acute cases all the 
elements of normal percussion sounds are exaggerated. 



DISEASES OF RESPIRATORY TRACT. 195 

The note is hyper-resonant, clear and slightly higher in 
pitch. 

In long-standing cases, secondary changes in the lung 
may cause loss of tension and the percussion sound of 
the large-lung emphysema. In chronic localized emphy- 
sema the percussion note varies according to the condi- 
tions with which it is associated. 

Auscultation. — La/rge-I/img Emphysema. — During 
inspiration the vesicular murmur is short, feeble, or 
may be inaudible, being replaced "by a low-pitched, 
rumbling sound of muscular contraction." (Fowler.) 
During expiration the breath sound is prolonged, and 
continues with nearly equal intensity to the end of the 
act. In direct proportion to the severity of the disease, 
the ratio of the length of inspiration to expiration is 
altered. Expiration becomes longer than inspiration, 
sometimes reversing the normal ratio, being four times 
as long as inspiration. The pitch is low, and the quality 
slightly blowing. When emphysema is associated with 
bronchitis and spasm of the bronchi, various-sized dry 
and moist rales are heard (spasmodic emphysema). 

When emphysematous blebs have formed beneath the 
pleura there is heard with inspiration and expiration, or 
both, fine crackles (fine crackling crepitations, emphy- 
sematous gurglings). With the failing right heart, 
fine, moist, crepitating rales, due to pulmonary oedema, 
are heard over the base of the lungs. 

Cardiac sounds are not heard over the normal area, 
and vary according as hypertrophy or dilatation is most 
marked. Over the apex of the heart the first sound is 
low pitched and prolonged in hypertrophy, short and 
sharp when dilatation and cardiac weakness occur. Over 
the base the cardiac sounds axe heard at a lower level 
than normal, and there is accentuation of the second 
sounds to the left of the sternum, due to increased ten- 
sion of the pulmonary artery. A systolic murmur is 
frequently present over the displaced apex ; at first this 
may be present only after exertion, or during transient 



196 THE RESPIRATORY SYSTEM. 

attacks of intercurrent bronchitis ; later it may be per- 
manent, with all the associated signs of tricuspid regur- 
gitation, Cardiorespiratory murmurs are at times 
present over the normal area of cardiac dullness. 

Small-Lung Emphysema.— The deviations from nor- 
mal are not as marked as in the large lung. The 
inspiratory sound is nearly normal in length, but feeble. 
The expiratory sound is prolonged, but rarely exceeds 
the length of inspiration ; is harsher, and its pitch is not 

as low. 

Compensatory Emphysema. — Breath sounds ^ are 
exaggerated. They retain their normal characteristics, 
but are puerile in type. 

Differential Diagnosis.— The distinctive signs of large- 
lung emphysema are bilateral enlargement /of the chest, 
with increase in the anteroposterior diameter and 
rounded contour (barrel-shaped chest) ; widening of the 
intercostal spaces ; restricted inspiratory movement, 
with prolonged and labored expiration ; displacement of 
the apex beat and epigastric pulsation. 

Feeble vocal fremitus, associated with hyper resonant 
and low-pitched percussion note. 

The inspiratory portion of the breath sounds is short, 
feeble or absent," while the expiratory portion is pro- 
longed, low pitched and relatively more intense. 

Pneumothorax.— Enlargement of the thorax is not 
symmetrical, but more marked over the affected side. 
The intercostal spaces of the affected side are obliter- 
ated. Movements of the two sides are unequal. There 
is absence of motion on the affected side, with active 
movement of the opposite. The heart is displaced 
toward the unaffected side. The percussion note is 
hyper-resonant, but of tympanitic quality, the normal 
pulmonary quality being absent. Coin test shows a 
peculiar metallic quality of sound. Vocal fremitus is 
absent. Vesicular murmur is absent. _ Amphoric 
breathing is present on inspiration and expiration when 
an opening to a bronchus is patent. Lung fistula sound 
is at times detected. 



DISEASES OF RESPIRATORY TRACT. 197 

Hydro-pneumo-thorax. — Below level of fluid there is 
flatness on percussion. On shaking the patient succus- 
sion sounds may be detected, with metallic tinkles. 

Cardiac Dyspnoea. — In acute febrile diseases and in 
anaemia, physical signs similar to those obtained in a 
mild degree of emphysema are frequently present, espe- 
cially the hyper-resonant, low-pitched percussion note. 
This is differentiated from true emphysema in that the 
respiratory sounds retain their normal relation to each 
other. 

ASTHMA. 

Asthma is a disease characterized by attacks of in- 
tense dyspnoea of a paroxysmal type, occurring more or 
less suddenly. 

Attacks of asthmatic dyspncea may he due to acute 
narrowing of the lumen of the bronchial tubes by fa) 
spasm of the muscles of the bronchi, or vasomotor dila- 
tation of the blood-vessels (idiopathic or true asthma), 
(b) inflammatory swelling of the mucous membrane 
(secondary asthma). 

Between the attacks in the primary type the respira- 
tory tract may be normal. In the second tvpe it shows 
the change of the disease which caused it 

Condition of Lungs During Asthmatic Attack. 
— In proportion to the intensity of the attack, there is 
increase in the amount of residual air and a correspond- 
ing decrease in the quantity of tidal air, with resultant 
overdistension of the alveoli. The chief factor in caus- 
ing interference with the normal movement of the air 
during inspiration and expiration is the spasmodic con- 
traction of the muscular tissue present in the bronchial 
tubes. Muscle fibres have been demonstrated in the 
bronchial tract as far as the infundibula. The muscle* 
fibres of the bronchi are passive during inspiration, but 
during expiration their contraction is an important fac- 
tor in forcing the air out of the lung and in the produc- 
tion of normal expiratory breath sounds. 



198 THE RESPIRATORY SYSTEM. 

During an asthmatic attack the normal rhythmical 
action of the bronchial muscles is disturbed. With ex- 
piration the contractions are excessive, narrowing the 
lumen of all the tubes, and even closing entirely the 
smaller ones, especially the non-cartilaginous. With the 
following inspiration active contraction of the muscle 
ceases, but more or less spasm remains, so that there is 
persistent interference with the movement of air in the 
lung ; but it is not so great as during expiration. In 
mild attacks the inspiratory obstruction may not be 
present. With each respiratory act more air is taken m 
than is expelled, until the thorax is distended to the ut- 
most; there is imperfect ventilation of the lung and 
deficient oxygenation of the blood, with attending 
symptoms of dyspnoea. The effect of an asthmatic at- 
tack is overdistension of the lung, causing depression of 
the diaphragm, enlargement of the thoracic cavity in all 
directions ; the heart is displaced downward and toward 
the median line. 

Contraction of the bronchi and overdistension of the 
alveoli cause diminution of the normal negative inter- 
thoracic pressure during inspiration, and may give rise 
to positive pressure during both inspiration and expira- 
tion, which in turn causes interference with pulmonary 
circulation, overdistension of the right ventricle, and in- 
terference with venous return circulation. 

With the subsidence of an attack, the pulmonary con- 
dition may return to normal. Kepeated and long-con- 
tinued attacks of asthma gradually produces permanent 
dilatation of the air-vesicles and secondary emphysema. 
Physical Signs. Inspection. — (a) During attack: 
The face may be pale or slightly cyanotic ; the patient 
generally sits in the position to give greatest leverage to 
auxiliary muscles of respiration ; the shoulders are ele- 
vated; the chest assumes the barrel shape of emphy- 
sema. With inspiration, the muscles of the neck, espe- 
cially the sterno-cleido-mastoid, are prominent, and 
cause the movements of the chest to be short and jerky, 



DISEASES OF RESPIRATORY TRACT. 199 

lifting the thorax en masse, but with very little expan- 
sion. Interference with the free entrance of air into 
the alveoli causes depression of the soft parts, so that 
the suprasternal, supraclavicular and intercostal spaces 
are deepened. The diaphragm is forced to the lowesl 
point possible, the lower portion of the thorax and ster- 
num are depressed, and the epigastric region becomes 
more prominent. Expiration follows inspiration with- 
out a pause, and is prolonged, labored, but feeble. Move- 
ment of thorax is very slight, and due to the action of 
Hie auxiliary muscles of expiration, which, forcing the 
bony thorax against the inflated lung, cause bulging of 
the intercostal spaces and supraclavicular fossae. Respi- 
rations are not increased in frequency, and may be 
loss than normal. Jugulars arc distended, and the apex 
beat is displaced downward and to the right, with 
marked epigastric pulsation. 

(b) Between the attacks: the condition of the lungs 
may be normal. When asthma has produced permanent 
dilatation of the air-vesicle, the shape and movement of 
the thorax are those of emphysema. 

Palpation. — (a) During attach: vocal fremitus 
never increased ; may be diminished or absent, Over a 
given area it varies from time to time, according to the 
degree of contraction of bronchi leading to the part. 
Rhonchi may be felt. The cardiac impulse is displaced 
downward to the right, and is diffused ; pulse is small 
and intermittent, especially during inspiration (pulsus 
paradoxus), (b) Between the attacks: vocal fremitus 
is normal or diminished if emphysema is present. 

Percussion. — (a) During attack: percussion sound 
hyper-resonant During early stage of the disease, with 
increased tension in the lung, the sound is slightly 
higher pitched, but clear. After repeated attacks, the 
diminished elasticity of the lung causes the pitch to be 
altered (lower) and the quality to be tympanitic or 
boardy (see Emphysema). Enlargement of the lung 
causes cardiac and hepatic areas of dullness to dis- 



200 TEE RESPIRATORY SYSTEM. 

appear. The borders of lungs are extended, and show 
no variation between inspiration and expiration, (b) 
Between the attacks: resonance may be normal or more 
or less emphysematous. 

Auscultation. — (a) During attacks: inspiratory 
vesicular murmur may be heard from time to time, 
When present, it is of normal quality, but weak, short 
and jerky. Usually it is absent or obscured by sibilant 
or sonorous rales. 

During expiration respiratory murmur is usually 
absent, being replaced by prolonged dry rales of sonor- 
ous, sibilant, cooing or whistling type, The rales are 
constantly changing in intensity and character over a 
given area, at times disappearing, either with return of 
normal vesicular murmur or absence of all sound. With 
subsidence of the attack, large and small-sized moist 
rales are present, due to secretion in the bronchi. 

Vocal resonance is normal or somewhat diminished; 
cardiac sounds during attack are masked by the dry rales 
in the lung. When asthmatic attacks occur during the, 
course of acute or chronic bronchitis, dry and moist rales 
are both present. 

(b) Between the attacks: respiratory sound may 
return to the normal, or a few wheezing rales may be 
present for some time after dyspnoea has disappeared. 
After severe attacks, fine, bubbling, moist rales, with 
feeble respiratory murmur, may be heard for some hours 
or days over the base of the lung and along the borders. 
In chronic cases, emphysematous breathing is present 

between the attacks. 

Differential Diagnosis. Cardiac Dyspnoea — Subjects of 
valvular and myocardial disease of the heart may suffer 
from intercurrent attacks of spasmodic dyspnoea. It 
has the following physical signs which differentiate it 
from asthma: 

Inspection. — The breathing is sighing or panting in 
character ; the rate is increased ; the movements of 
inspiration and expiration are of nearly equal length. 



DISEASES OF RESPIRATORY TRACT. 20 J 

Expiration lacks the characteristic prolongation of 
asthma. The chest lacks the typical distension of 
asthma. In asthma the breathing is spasmodic, with in- 
spiration short; expiration, prolonged and labored. The 
rate of respiration not increased. 

Percussion. — In cardiac dyspnoea the note over the 
upper portion of the chest is normal. Over lower por- 
tion of the chest, especially at the base, posteriorly, dull- 
ness is more or less marked, in proportion to the amount 
of pulmonary oedema and passive congestion. 

In asthma the note is hyper-resonant over all portions 
of the chest, especially at the base. 

Auscultation. — In cardiac dyspnoea during inspira- 
tion, vesicular murmur is present over upper portion of 
lung: over base it may be feeble or absent, according to 
the amount of pulmonary congestion and oedema. 

The relative length of inspiration and expiration is 
but slightly altered. Rales, both dry and moist, may be 
present, but dry rales are not as varied and are more 
constant than in asthma ; while moist rales are relatively 
more abundant, especially over the base. In chronic 
passive congestion (cardiac pneumonia) the breath 
sounds may have a bronchial quality. When dyspnoea 
is due to valvular disease, the physical signs of the lesion 
are usually present. At times the asthmatic signs in 
the lung may be intense enough to mask the cardiac 
murmurs. 

In asthma dry rales are the most prominent. When 
detected, breath sound is normal, never bronchial. 

Laryngeal and Tracheal Stenosis. — Inspection. — 
Dyspnoea is inspiratory with increased movement of 
the larynx. Size of the chest is diminished ; the dia- 
phragm is elevated ; there is marked retraction of the 
suprasternal, supraclavicular and intercostal spaces. 
Inspiratory portion of respiration is prolonged and 
labored. Expiratory movement is shorter than normal. 
In asthma the dyspnoea is chiefly expiratory ; the chest 
is enlarged ; the diaphragm is depressed. 



202 THE RESPIRATORY SYSTEM. 

Percussion. — In stenosis the percussion note has 
diminished resonance. In asthma it is hyper-resonant. 

Auscultation. — In stenosis, vesicular murmur over 
the lung is diminished or feeble ; the stridor, clue to the 
narrowing of the larynx, frequently causes bronchial 
type of breathing to be heard over both lungs. The 
changes' in the respiratory sounds are constant. ^ In 
asthma, dry rales of varying size are heard over a given 
area, constantly changing in character. 

Aneurism of the Aorta. — Compression by the aneuris- 
mal sac of the trachea and left bronchus may simulate 
very closely an asthmatic attack. The physical signs 
are not bilateral. The intensity of the signs will depend 
on the degree of narrowing.' When the bronchus is only 
slightly narrowed, the respiratory sound heard over the 
lung beyond the point of constriction may have^ a 
slightly tubular or a marked sonorous quality. Entire 
occlusion of the bronchus causes absence of breath sound 
over portion of lung supplied by the tube. Dullness 
over the sternum and tracheal tugging, brassy cough, 
and heaving impulse are generally sufficient for diag- 
nosis. 

Hysterical Breathing.— Paroxysmal and labored breath- 
ing, similar to that of asthma, occurs during hysterical 
attacks. Expansion of the chest, due to voluntary 
action of the muscles of inspiration, and voluntary inter- 
ference with expiration, may be identical with that of 
asthma, The rate of the breathing is generally 

increased. 

On auscultation the dry rales, with prolonged expira- 
tion, are not present. 

PULMONARY TUBERCULOSIS. 

Synonyms. — Phthisis, consumption. 
"Pulmonary tuberculosis is a disease of the lungs, due 
to the presence of the tubercle bacilli, with the produc- 
tion of tubercular 1 nodules. 

The distribution of the tnbercules may be localized or 



DISEASES OF RESPIRATORY TRACT. 203 

diffuse. The primary effect is the same in both cases, 
varying merely in degree. When localized, its point of 
selection is usually the apex, although certain factors 
may determine its primary location in other portions of 
the lung. When more widely distributed, it may in- 
volve an entire lobe or lung, or may be disseminated 
throughout the entire bronchial tract. 

Effect Upon the Lung. — Immediate lodgment of the 
tubercle bacilli usually occurs in the terminal bron- 
chioles. With the production of the tubercular nodule, 
the bronchiole becomes occluded, and the alveolus sup- 
plied by the bronchiole becomes the scat of an inflamma- 
tory process, with the production of broncho-pneumonia. 
The peribronchial tissue is also involved. Extension to 
neighboring lobules occurs through the lymph spaces 
and vessels into the interstitial tissue, and also through 
the bronchi. On account of the relation of the lymphat- 
ics of the interlobular tissue to the pleura, there is early 
extension to the subpleural tissue, with secondary in- 
volvement of the pleural sac, which may, however, not 
be of a tubercular nature. 

Secondary Changes. — Dependent upon tubercular in- 
fection, three varieties of pathological changes occur: 
(1) Congestion, inflammation and cedeina of the tissues 
adjacent to the tubercular nodule, producing more or 
less complete consolidation of the alveoli with inflam- 
matory products (catarrhal, broncho-pneumonia). (2) 
Xecrosis (caseation, liquefaction, softening) of the in- 
fected area. (3) Growth of connective tissue (fibrosis). 
These three processes occur together, and are present in 
varying degrees. As one or another predominates in an 
individual case, the rapidity of its course and the type 
of the disease is determined. 

Two forms of pulmonary tuberculosis occur : A. 
Acute. B. Chronic. These can be still further sub- 
divided into types, according to (a) distribution of the 
infection; (b) the character of the changes in the in- 
fected area. 



204 THE RESPIRATORY SYSTEM. 

A. Acute Pulmonary Tuberculosis. 

Three types may be recognized clinically : (1) Acute 
miliary tuberculosis, pulmonary type. In this form of 
the disease the tubercle bacilli are widely distributed 
throughout the lung. The eruption of tubercles is^ very 
rapid, and the inflammatory changes in the alveoli and 
adjacent bronchi are very marked. These early changes 
in the lung are almost identical with those that occur in 
acute capillary bronchitis with involvement of the 
alveoli. The necrosis and liquefaction occur almost at 
once, while there is almost complete absence of con- 
nective tissue increase. 

(2) Broncho-pneumonic type. In this form the 
eruption of tubercular nodules is at first localized in the 
apex of one or both of the upper lobes, or tubercular 
foci may be scattered throughout the lung. The areas 
involved in the tubercular process are the seat of an 
intense catarrhal inflammation, and caseation with 
liquefaction and cavity formation occurs very rapidly, 
so that the lung passes in a short time through the stages 
of infection, tuberculization, infiltration (broncho- 
pneumonia), and softening, with the production of a 
number of small cavities. The tubercular masses may 
coalesce, forming a confluent broncho-pneumonia. 

(3) Lobar type. Occasionally the amount of tissue 
involved by confluent areas of tubercular broncho- 
pneumonia may be so great as to involve nearly au 
entire lobe, giving consolidation as extensive as is found 
in acute croupous pneumonia. 

On account of the rapidity of the changes and the 
nature of the physical signs, various names have been 
given to this form of acute pulmonary tuberculosis, as 
acute phthisis, acute pneumonic phthisis, tubercular 
pneumonic phthisis, caseous tubercular pneumonia, 
broncho-pneumonic phthisis, acute catarrhal phthisis, 
epithelial phthisis, florid phthisis, galloping consump- 
tion. 



DISEASES OF RESPIRATORY TRACT. 205 

Physical Signs. — In the acute miliary type the earliest 
changes may be those of general bronchitis, gradually 
increasing in intensity with the occurrence of broncho- 
pneumonia. In the early stage of acute miliary tuber- 
culosis the signs are identical with those described 
under Capillary Bronchitis with involvement of the 
bronchioles and alveoli (page 155) ; the dyspncea, how- 
ever, is more marked and persistent. Where the disease 
is localized the following signs may be present: 

Inspectiox. — In the broncho-pneumonic type, in the 
early stage, there is no change in the shape of the che-t. 
With occlusion of a large number of bronchi and pul- 
monary collapse there is depression of the thorax over 
the affected area, with loss of motion. With the occur- 
rence of liquefaction (softening) and the formation of 
cavities the depression may become less marked and 
motion may return. 

In the lobar type there may be loss of motion over a 
wider area, while more complete consolidation of the 
lung causes absence of thoracic depression. 

Palpation. — In the broncho-pneumonic type vocal 
fremitus may be normal when the disease is deep seated, 
and feeble when there is marked pulmonary collapse. 
When the consolidation is close to the surface, vocal 
fremitus is slightly increased. 

In the lobar type vocal fremitus may be as intense 
as in true croupous pneumonia. 

Percussion. — In the early stage the percussion note 
may be normal. Over the portion of lung affected by 
obstruction of the bronchi the percussion note is dull, 
with slight tympanitic quality. Later there is gradual 
increase of dullness, according to the degree of consoli- 
dation. When pleural changes are present, dullness 
mav almost reach the decree of flatness. With cavitv 
formation the dullness is replaced by cavernous or am- 
phoric percussion resonance. 

Auscultation. — The earliest signs over the affected 
area are those of diffuse bronchitis, with sibilant and 



206 THE RESPIRATORY SYSTEM. 

sonorous rales and moist rales of a liquid, bubbling 
character. Tire breath sounds may be weak in occlu- 
sion of the bronchioles and pulmonary collapse. As the 
collapsed lung becomes consolidated by inflammatory 
products the breath sounds become bronchial in char- 
acter, but rarely as intense as in lobar pneumonia. The 
liquid, bubbling rales of bronchitis are replaced by 
sharp, crepitating rales and by pleuritic friction sounds. 
As softening occurs the small rales are replaced by 
coarser ones, and the bronchial breathing loses its sharp- 
ness and has a hollow, blowing quality ; it rarely becomes 
markedly cavernous or amphoric. The slower the course 
of the disease the greater the tendency for the areas of 
consolidation to coalesce, with a corresponding increase 
in the intensity of the bronchial quality of the breath 
sounds. As the different tubular areas do not undergo 
the changes of consolidation, softening and cavity forma- 
tion with the same degree of rapidity, the physical signs 
of all stages of the disease will be found in different por- 
tions of the lung. In the localized broncho-pneumonic 
and lobar types the disease may at any stage lose its 
acute character and pass into the subacute or chronic 

form. 

Differential Diagnosis. Simple Broncho-Pneumonia, 
—As stated above, the early physical signs are identical 
in the tubercular and non-tubercular forms. As the dis- 
ease advances to the stage of softening, slight differences 
may be noted. In the simple, non-tubercular pneumonia 
resolution occurs at a uniform rate over the affected 
areas, with a gradual return to the normal condition. 
In the tubercular type, with softening and destruction 
of the lung tisue, rales become larger than those present 
in bronchi of normal size. The bronchial character 
of the breath sounds is gradually replaced by soft, blow- 
ing, puffing breath sounds, especially marked on expira- 
tion. In the lobar pneumonic form the physical signs 
may be for a time identical with those of croupous 
pneumonia, but later certain changes develop in the 



DISEASES OF RESPIRATORY TRACT. 207 

consolidated lung which differ. The vocal fremitus 
over the consolidated area, while it may be as intense as 
that found in the second stage of croupous pneumonia, 
is not uniform over all portions of the lobe involved. 
During the period of softening, vocal fremitus does not 
diminish to the same degree in the tuberculous cases. 
On auscultation, fine crepitating vales of the first stage 
of croupous pneumonia may be present, but they are not 
as fine nor as sharp, and do not occur in well-defined 
showers. They do not disappear with the occurrence of 
bronchial breathing, as in croupous pneumonia, but per- 
sist until replaced by the coarser rales of softening. 
With the beginning of softening, the rales of tubercular 
pneumonia may be identical with those of resolving 
croupous pneumonia (rales redux), but they tend to 
become larger, and are later replaced by mucous clicks 
and gurgles. In croupous pneumonia the rales are 
uniform in size, and become fewer as resolution occur-. 

The bronchial breathing of tubercular pneumonia 
does not disappear with the signs of softening, but, 
while it may for a time be more or less masked by rales, 
it reappears over scattered areas and has a hollow, 
cavernous or amphoric quality. In croupous pneu- 
monia the bronchial quality of the breath sounds grad- 
ually fades out as resolution progresses. 

AVhile the above physical signs may aid in differen- 
tiating tubercular from non-tubercular lobar pneumonia, 
the most important data are obtained by the tempera- 
ture, duration and course of the disease, and micro- 
scopical examination of the sputum. In tubercular 
pneumonia the physical signs of softening are not asso- 
ciated with the phenomenon of crisis and lowered range 
of temperature. The expectoration of tubercular pneu- 
monia is apt to be grayish-green (Traube), differing 
markedly from the tenacious, blood-stained (brick dust) 
sputum of croupous pneumonia. 



208 THE RESPIRATORY SYSTEM. 

(B) Chronic Pulmonary Tuberculosis. 

In the subacute and chronic forms of pulmonary 
tuberculosis, following local infection by the tubercle 
bacilli, pathological changes occur which are of the 
same general nature as those of the acute form, but 
differ in the degree of severity and in their course, 

In these forms the disease is more distinctly localized, 
With the development of the tubercular nodules there 
may be congestion, inflammation and oedema of the 
affected lobules, giving the pathological changes and 
physical signs of localized acute bronchitis or acute 
pneumonia, as was described in the acute forms. These 
acute conditions subside, and the disease runs a milder, 
more subacute or chronic course. In the large majority 
of cases the incipient stage is more insidious, and with 
the local infection there is little or none of the acute 
inflammatory change, but a progressive increase of the 
connective tissue (fibrosis), which extends outward 
from the site of infection along the interlobular septa 
to the surface of the lung, and early involves the 
subpleural and pleural surfaces, causing thickening and 
adhesion. The bronchi in the affected area are nar- 
rowed or occluded, with subsequent pulmonary collapse. 
The fibrosis and changes in the bronchi and alveoli 
cause imperfect expansion of that portion of the lung 
and retraction of the tissues of the thorax over it, unless 
the functionless portion is compensated for by the 
adjacent overlying lobules. During the early or 
incipient stage all degrees and extent of these patho- 
logical changes may be present at different times m the 
same case. Their relative preponderance determines 
the type of the disease and influences its course. I he 
physical signs present will be those of localized bron- 
chitis, catarrhal pneumonia, fibrosis and pleurisy The 
more marked the fibrosis the more latent and chronic 

the course. 

The disease may be arrested in this stage by encapsu- 
lation of the tubercular area by a dense fibrous envelope. 



DISEASES OF RESPIRATORY TRACT. 209 

Usually (second stage) there is extension of the tuber- 
culous infiltration to adjacent portions of the same lobe, 
as described below. This extension is along fairly 
definite lines, and is usually associated with more or less 
consolidation, due to filling of the alveoli with inflam- 
matory products, and to connective tissue increase. W itli 
the extension of the disease there is corresponding in- 
volvement of the pleura, which may be acute, sub- 
acute, adhesive or pleurisy with effusion. The con- 
solidation is never as complete as in croupous pneu- 
monia. 

Sooner or later, in the majority of cases, necrosis 
(third stage) of the tubercular areas occurs, followed 
by liquefaction and softening, with the formation of 
cavities of varying sizes. These later changes may first 
show themselves in the primary focus, or, when fibrosis 
has been more marked, condensation may occur without 
cavity formation; while breaking down occurs in those 
portions secondarily affected. This tendency of chronic 
pulmonary tuberculosis to necrose and form cavities has 
given it the name of chronic ulcerative tuberculosis. 
Necrosis and softening occur especially in those cases 
in which the inflammatory changes (broncho-pneu- 
monia) have been most marked. Where fibrosis has 
predominated, the disease may present the changes that 
were described vuider chronic interstitial pneumonia 
(page 185). Of equal importance with the pathological 
changes and physical signs is the distribution of the 
primary foci and the manner of extension of the disease 
throughout the pulmonary system. 

" Tubercular disease, in its onward progress through 
the lung, in the majority of cases follows a distinct 
route, from which it is only turned aside by the intro- 
duction of some disturbing factor/' ("Localization of 
Lesions of Phthisis," Fowler.) 

Site and Progress of Pulmonary Tuberculosis. — 
The most common point of primary infection is at 
the apex of the upper lobe of the lung, 1 to 1% inches 

14 



210 THE RESPIRATORY SYSTEM. 

below the summit. This may be either on the anterior 
or posterior border. Anteriorly, this point corresponds 
to the supraclavicular and the infraclavicular space 
opposite the middle of the clavicle, posteriorly to the 
supraspinous fossa. From this point of origin the dis- 
ease tends to involve the upper lobe, following along the 
anterior border. Yet not infrequently the primary 
localization is on the outer portion of the upper lobe, 
corresponding to the first or second interspaces, just 
below the outer third of the clavicle — a localization 
less favorable for arrest or cure than the first. After 
involvement of one upper lobe, the secondary tubercular 
deposit may appear at the apex of the opposite lung, 
but generally there is early involvement of the upper 
portion of the lower lobe on the same side, at a point 
which corresponds to the midscapular space opposite 
the fifth dorsal spine. When the physical signs over 
the apices of the lung are doubtful, the presence of a 
change in the breath sounds or the occurrence of rales 
over this position is of great diagnostic value, as it, 
almost invariably indicates that the signs at the apex 
are due to tubercular changes. The base of the lower 
lobe is rarely primarily affected, so that if the respira- 
tory sounds over the apices are normal much caution 
must be exercised in pronouncing the changes that occur 
at the lower portion of the lower lobes tubercular. 
Secondary foci in the upper portion of the lower lobe 
occur soon after primary infection of the upper lobe on 
the same side, generally extending backwards along the 
posterior surface of the lung and along the line of inter- 
lobular septa. The interlobular septa and the area of 
usual extension correspond to the lower border of the 
scapular when the arm is raised above the level of the 
clavicle, and the hand carried well over the shoulder of 
the opposite side until the finger tips rest upon the spine 
of the scapula. Extension downward generally occurs 
by the development of separate foci, and not by gradual 
extension from the upper portion of the lobe. Primary 



DISEASES OF RESPIRATORY TRACT. 211 

basic tuberculosis is extremely rare. In estimating the 
probability of basic lesions being tubular in origin, the 
following points must be considered : 

1. If the physical signs of the disease in the lower 
lobe are continuous from apex to base, it is probably 
tuberculosis. 

2. If the base is affected, but the upper part of the 
lower lobe is free from all change, the basic lesion is 
probably (a) non-tubercular; it may be collapse follow- 
ing bronchiectasis, catarrhal pneumonia, pneumonia or 
pleurisy, (b) "If tubular, it is secondary to some con- 
dition which has diminished the normal resisting power 
of the base, i. e., pleurisy followed by partial collapse, 
for example ; but the presumption is strongly in favor of 
non-tubercular lesion. ' ' ( Fowler. ) 

The apex of the opposite lung is generally involved 
after the lower lobe on the primarily affected side. The 
lesion has usually the same site as in the lobe primarily 
affected, but may be close to the interlobular septum, 
corresponding on the chest wall to the upper part of the 
axilla. The middle lobe of the risrht lunff is rarelv the 
seat of the primary lesion. It is generally affected 
rather late by extension from the upper lobe on the same 
side, and may escape entirely. 

Physical Signs. — The physical signs present in sub- 
acute and chronic pulmonary tuberculosis during the 
different stages vary with the nature of the pathological 
changes, at one time approaching those of the acute 
type, to again become less acute, closely simulating 
those of chronic bronchitis, chronic interstitial pneu- 
monia or chronic pleurisy. One of the most distinctive 
features of the physical signs of chronic pulmonary 
tuberculosis is their localization for a longer or shorter 
time, especially at the apex, and their gradual extension 
throughout the lung. This fact allows of division of 
the signs into those diagnostic of three stages of the dis- 
ease: (1) The early or incipient stage; (2) the stage 
of extension and consolidation, and (3) the stage of 



212 THE RESPIRATORY SYSTEM. 

softening and excavation. These stages cannot be de- 
fined with positive sharpness, but they are useful to 
indicate the nature of the preponderating pathological 
changes; and the same case may show all stages present 
in different portions of the lung, or even in one lobe. 

Inspection. Early or Incipient Stage. — The 
thorax over the infected area may show no change in 
size or shape, or there may be depression of the bony 
thorax. Deformity of the chest does not occur until the 
changes in the lung, secondary to the infection of the 
tubercular bacilli, have interfered with the distensibility 
of the affected areas, either by rendering the pulmonary 
tissue inelastic (fibrotic) or by interfering with the 
entrance of air into the bronchi with secondary atelecta- 
sis. The above changes may be compensated for by 
emphysematous dilatation of the alveoli of the surround- 
ing lobules. Extensive tubercular infiltration may be 
present with a normal appearing chest. 

Flattening of the upper portion of the thorax is sug- 
gestive of tuberculosis, especially when the flattening 
is limited to the apex. Frequently it can only be noted 
when the patient is lying flat or when looking down 
over the shoulder. Such flattening at the top may occur 
with a good antero-posterior diameter below. 

When fibrosis and pulmonary collapse are the pre- 
dominating pathological changes the deformity of the 
thorax is marked. There is deepening of the supra- 
and infraclavicular spaces, and retraction of the first 
and second ribs, and the clavicle becomes somewhat 
prominent. With these changes in the bony thorax, 
the expansion over the affected area is markedly dimin- 
ished, while that of the opposite side is increased. 
Pleural involvement with pain gives still further 
diminution of motion. Changes in the bony thorax 
may be entirely absent when dilatation of the air-vesicles 
(compensatory emphysema) occurs around the affected 



area. 



Second Stage. — As the disease advances the signs 



DISEASES OF RESPIRATORY TRACT. 213 

noted by inspection are influenced by the amount of 
fibrous induration present. When this is slight the 
chest may show very little deformity, although motion 
of the thorax may be markedly diminished. When 
fibrous thickening of the lung is marked there is local- 
ized flattening of the chest and marked loss of expan- 
sion. Extension of the disease to the upper portion of 
the lower lobe causes the scapula on the affected side to 
become more prominent, while at the same time there 
may be curvature of the spine. 

Third Stage. — With the occurrence of softening when 
the pneumonic changes have been the most marked feat- 
ure, with a slight amount of fibrosis, the deformity of 
the previous stage may be lessened, while at the same 
time expansion over the affected area becomes freer. 
Frequently, when the apex of one lung is in the third 
stage, with early secondary involvement of the opposite 
side, the expansion will be freer on the side first 
affected. 

In some cases marked softening with cavity forma- 
tion does not occur, being replaced by interstitial 
changes in the affected area. In these cases there is 
marked contraction of the chest, producing curvature of 
the spine. When situated in the upper portion there 
is depression of the shoulder, with projection of the 
scapula. The intercostal spaces are depressed, and the 
ribs may overlap each other; expansion is diminished 
or absent. When the upper lobe of the left side is 
affected the apex beat of the heart is displaced upward 
and slightly outward, and may be seen in the third left 
interspace, or even higher. When the lower lobe of the 
left side is involved the apex beat may be seen in the left 
axilla. Fibrosis of the right upper lobe causes the 
heart to be displaced toward the right, the apex beat 
frequently being invisible, because it is under the 
sternum. ' Contraction of the right lover lobe causes 
the apex beat to be seen at times beyond the right border 
of the sternum. 



214 TEE RESPIRATORY SYSTEM. 

Palpation. Early or Incipient Stage. — It must be 
borne in mind that vocal fremitus beneath, the right 
clavicle is greater than that on the left, and serves as a 
standard for comparison. If vocal fremitus is equally 
well marked on both sides it indicates that there is 
either diminution on the right side or increase on the 
left. 

In the early stage vocal fremitus may be normal, 
increased or diminished over the affected area. It is 
normal when the lesion is deep seated and covered with 
normal lung; increased when there is inflammatory 
change or marked fibroid thickening; diminished when 
pulmonary collapse or pleuritic thickening is marked. 
Change in vocal fremitus in tuberculosis is to be taken 
in connection with the other physical signs. Palpation 
is frequently more accurate than inspection in showing 
slight change in the expansion over the apices. 

Second Stage. — With extension of the disease beyond 
the primary foci, vocal fremitus may show the same 
variations as noted during the first stage. Usually 
extension is accompanied by well-marked inflammatory 
changes in that portion of the lung that is secondarily 
affected, and there is a corresponding increase in vocal 
fremitus. Involvement of the upper portion of the 
lower lobe causes increased vocal fremitus over the 
interscapular space. Further extension over the lower 
lobe causes increased vocal fremitus in parts which are 
not contiguous. Involvement of the opposite side of 
the upper lobe may show the samle changes as those that 
occur in the primary foci. 

Third Stage. — Vocal fremitus may be increased with 
the beginning of softening, due to the occurrence of 
acute exacerbations, which frequently accompany this 
change. When cavities are formed, vocal fremitus 
becomes less marked. When fibroid changes predomi- 
nate in the later stages, it may be increased. Thicken- 
ing of the pleura frequently causes diminution of vocal 
fremitus. 



DISEASES OF RESPIRATORY TRACT. 215 

Percussion. First Stage.— The percussion note 
may be unchanged, but the earliest departure from 
normal is usually a slight rise of pitch, with diminution 
of resonance. Percussion of the apex is most impor- 
tant, especially comparative percussion of the two 
apices. (See page 98.) In percussion of the apex 
care must be taken that the percussion blow is not 
toward the trachea. Percussion over the sternocleido- 
mastoid muscle is not reliable, as it is modified by the 
tracheal note. The percussion note over the affected 
apex may be hyper-resonant when the more superficial 
alveoli have undergone compensatory dilatation. Any 
change in the percussion note, either giving dullness or 
hyper-resonance, demands close investigation. Percus- 
sion should be uniform and not too forcible, and the 
tissues of the thorax should be lax. The height to 
which the apex of the lung rises above the clavicle dur- 
ing inspiration and expiration should be determined, as 
diminished expansion on one or both sides is frequently 
the earliest symptom. Posteriorly, dullness on percus- 
sion, with marked heightening of the pitch, may be 
noticed in the supraspinous region. Thickening of the 
pleura causes the note to be dull and higher pitched, 
with increased sense of resistance. 

Second Stage. — As consolidation extends, dullness 
will be detected along the edge of the sternum, and 
extending toward the axillary Hue. Careful percussion 
should be made at the apex and in the axillae in all cases. 
Involvement of the upper portion of the lower lobe 
causes marked dullness in the interscapular ^ space. 
When one apex is affected, careful examination for 
change in pulmonary resonance should be made fre- 
quently over the opposite apex. 

Third Stage. — Softening in the affected area may 
early cause a slight return of resonance, with tympanitic 
quality over the area where the percussion was dull and 
high pitched during the stage of consolidation. With 
destruction of lung tissue and the formation of a cavity, 



216 TEE RESPIRATORY SYSTEM. 

the percussion note becomes cavernous or amphoric, 
according to the condition of the walls of the cavity. 
Marked pleuritic thickening with fibroid change causes 
the note to become dull, with a well-marked boardy or 
wooden quality. 

Auscultation. Early or Incipient Stage. — As tu- 
berculosis most frequently affects the apex of the lung, 
the attention should be especially directed to the exam- 
ination of the apex in the supra- and infraclavicular 
fossae, the supraspinous fossa and the region of the hilus. 
In early or suspected cases repeated examinations may 
be absolutely necessary, always corrected by the results 
of percussion and palpation. The earlier signs of 
tubercular infiltration are (1) the occurrence of adven- 
titious sounds or rales, and (2) changes in the respira- 
tory murmur. Usually the earliest signs are the occur- 
rence at the apex of fine, moist rales, which are heard 
during inspiration. Two kinds of small, moist rales 
may occur in the incipient stage of tuberculization, (a) 
crepitations, when the localized exudation is merely 
serous or (Edematous, and (b) sharp, sticky clicks, which 
occur when there is more intense inflammatory change 
(broncho-pneumonia). These may be detected only 
after coughing, and may be limited to one or two rales. 
An important feature of these rales is their persistence 
at the point where first heard. Especially suspicious of 
tuberculosis is the absence of sputum associated with 
the presence of fine moist rales, which are most 
abundant after coughing and are not altered by it. Tu- 
berculous crepitations may be accompanied by dry 
wheezing rhonchi, or the rhonchi alone may be heard. 
Tubercular rhonchi are distinguished from those of gen- 
eral bronchial catarrh or asthma in that their localization 
is persistent and they are constantly detected in the same 
limited region. Dry rales over one apex at times pre- 
cede even moist crepitations, and are associated with 
feeble inspiratory breath sounds. These auscultatory 
signs generally antedate the early signs noted by inspec- 
tion, palpation and percussion. 



DISEASES OF RESPIRATORY TRACT. 217 

The respiratory murmur may be affected in various 
ways during the incipient stage. It may be (a) feeble, 
wavy or jerky in inspiration or expiration, or in both. 
This change is generally associated with occlusion of 
the bronchioles and collapse of the air-vesicles. (b) 
Wavy inspiration, with prolonged. high-pitched, slightly 
blowing expiration. This occurs when there is more 
marked increase in fibrous tissue, (c) The inspiratory 
breath sounds are harsher, higher pitched, with slightly 
tubular quality, while the expiratory is prolonged 
that it- length equal- or exceeds that of inspiration: its 
pitch is higher and it- quality blowing or tubular when 
the inflammatory changes are most marked (broncho- 
pneumonia). 

it is necessary to call attention again to the normal 
breath sounds that may occur over the right apex. 
Normally, these are slightly harsher than on the left 
side, and in certain anatomical arrangements the 
bronchi themselves may have a well-marked tubular 
quality. The relative intensity of the breath sounds on 
the two sides has the same diagnostic importance as the 
Vocal fremitus. 

Second Stage. — As the disease advances the auscul- 
tatory signs change, according to (1) the extent of 
consolidation, giving the more intense type of bronchial 
breathing; (2) whether or not there is accompanying 
bronchitis when dry and moist rales are present : I : 
fibrosis and induration, causing marked increase in the 
length of expiration; the bronchial element is not 
as marked, but is higher pitched than in the broncho- 
pneumonic type. (4) Thickening of the pleura causes 
various types of friction rales to be heard, with diminu- 
tion or absence of the breath sounds. ) Compensa- 
tory distension of the lobules -urrounding the affected 
area sufficient to cause the signs of consolidation to ba 
masked by those of compensatory emphysema. 

Secondary involvement of the upper portion of the 
lower lobe is shown by fine rales and pleuritic crepita- 



218 TBE RESPIRATORY SYSTEM. 

tions, with tubular breathing in the interscapular space 
and ever the hilus of the lung. The character of the 
breathing heard at this point is peculiar, on account of 
the relation of the upper portion of the lower lobe to the 
primary bronchi. 

Third Stage. — The occurrence of moist rales and 
their change in size when bronchitis has been a promi- 
nent symptom are the first evidence of softening. At 
first these rales have, in addition to their liquid quality, 
one of sharpness, dependent upon the consolidated con- 
dition of the lung in which they are made. But the 
conversion of the consolidated area into a cavity causes 
the breath sounds of the second stage to be changed in 
character. The pitch is lower, and the well-marked 
tubular quality is replaced by one of more hollow char- 
acter, cavernous or amphoric. If the cavities are dry, 
no rales may be present. If they contain fluid, rales of 
large size (gurgles) will be present. 

Vocal resonance over the area of softening changes 
in intensity, the broncophony and pectoriloquy of the 
stage of consolidation being replaced by amphoric or 
cavernous voice sounds. The stage of softening is 
rarely uniform throughout different portions of the 
lung, except in the more acute forms of the disease. 

ACTINOMYCOSIS. 

Infection of the lung by the ray fungus occurs gener- 
ally secondary to that of the mouth or other portions of 
the respiratory tract. Occasionally it may occur 
primarily in the lung. Clinically, two stages are recog- 
nized. 

First Stage. — This is characterized by gradual involve- 
ment of the lung and pleura. During this stage the 
physical signs are those of tuberculosis of the lung or 
empyema, according as the pulmonary or pleural in- 
volvement is predominant. Usually the primary focus 
is at the base of the lung. 



DISEASES OF RESPIRATORY TRACT. 219 

Inspection. — Restricted motion over the lower por- 
tion of the affected side. With extensive involvement 
of the lung or pleura there is increased bulging. 

Palpation. — As there is more or less occlusion of the 
bronchi in the affected area, vocal fremitus is dimin- 
ished. Extension to the pleura is attended with absence 
of vocal fremitus. 

Pekcussion. — Flatness, with increased sense of 

resistance. 

Auscultation. — Feeble or absent respiratory mur- 
mur and pleuritic frictions. 

Second Stage. — This is characterized by extension of 
the growth to the chest wall, and the involvement of the 
various structures. 

Inspection. — There is absence of motion over the 
affected area. The intercostal spaces are filled. Infil- 
tration of the soft parts causes localized inflammatory 
signs. With necrosis of affected tissue, there is dis- 
charge of characteristic pus. 

Palpation. — Over the intercostal tissue there is a 
sense of hardness in the interspaces and a brawny, 
(edematous condition of the soft parts externally. With 
breaking down, before free opening occurs, fluctuation 
may be detected. 

Percussion. — Before the opening occurs on the sur- 
face of the chest the signs may be that of localized em- 
pyema. The percussion outline does not follow that 
of effusion into the free pleural cavity, although it may 
be identical with that of localized empyema. The diag- 
nosis can frequently be made by puncture and micro- 
scopical examination of the fluid obtained. 

SYPHILIS OF THE LUNG. 

Syphilitic lesions of the lung may occur as (1) 
gumma, (2) lobar pneumonia, (3) interstitial pneu- 
monia (syphilitic phthisis), (-i) involvement of the 
bronchial glands and lymphatics. Destructive disease 
of the lung due to syphilis is very rare. 



220 



THE RESPIRATORY SYSTEM. 



The physical signs that accompany the different 
changes in the lung are closely allied to those dependent 
upon tubercular infection, and are not distinctive. 
Diagnosis depends largely upon the distribution of the 
foci and the subsequent course. 



Tubercular Disease. 

Pulmonary tuberculosis pri- 
marily involves the apex, and its 
extension throughout the lung 
follows a definite line. 

Coincident with the extension 
of the disease, softening and cav- 
ity formation occur. 

When cavities occur they tend 
to enlarge, with concurrent signs 
of softening and consolidation. 

Fibrosis in pulmonary tuber- 
culosis is usually attended with 
secondary changes of consolida- 
tion and softening. 

Stenosis of the bronchi rare. 



Syphilitic Disease. 

Syphilis usually affects the 
hilus and middle lobe of right 
lung, and extends through the 
lower lobe. The left lung is 
rarely affected. 

With extension, softening and 
destruction of lung tissue rarely 
occur. 

Cavities, when present, are of 
the bronchiectatic type and are 
attended with the signs described 
under bronchiectasis. 

Fibrosis is excessive, and its 
distribution through the lung 
follows the line of the lymphatics 
in the interlobular spaces. 

Stenosis of bronchi and larynx 
is commonly associated with 
change in the glandular struc- 
tures at the hilus. 



In many cases the differential diagnosis can be based 
only on repeated examinations of the sputum and the 
absence of tubercle bacilli, especially when signs of 
softening and bronchitis are present, 

MALIGNANT DISEASE OF THE LUNGS. 

Malignant disease of the lungs may be primary or, 
what is more usual, be due to extension from the medias- 
tinum and adjacent structure, or from metastasis from 
different portions of the body. It is especially liable to 
occur after operations on the mammary gland. 



DISEASES OF RESPIRATORY TRACT. 221 

Physical Signs. — These are variable, according to the 
site of the disease and the structures that are involved. 
The most distinctive forms are (1) primary carcinoma 
of the pulmonary tissue, involving more or less com- 
pletely a pulmonary lobe or the entire lung; (2) car- 
cinoma beginning in a large bronchus; (3) secondary 
carcinomatous nodules scattered through different por- 
tions of the pulmonary tissue. 

1. Pulmonary Carcinoma Involving the Pul- 
monary Tissue. Inspection. — Change in the size and 
shape of the thorax varies according to the site and ex- 
tent of the involvement. If located in the lower portion 
of the lung there will be enlargement of the affected 
side, bulging of the intercostal spaces, loss of motion 
similar to that which occurs in pleurisy with effusion. 
If it involves the upper lobe there will be filling out of 
the supraclavicular and infraclavicular spaces, with loss 
of motion. If, on the other hand, interstitial form 
predominates, there will be retraction of the chest wall 
over seat of neoplasm similar to that which occurs in 
interstitial pneumonia due to any cause. 

Palpation. — Palpation will show increased vocal 
fremitus, depending upon the extent of the consolidation 
and whether or not the bronchial tubes leading to the 
affected areas are open. In the majority of cases vocal 
fremitus is diminished or absent. 

Percussion. — There is marked dullness or flatness 
over the affected area. 

Auscultation. — There will either be a feeble or en- 
tire absence of the respiratory murmur, or if there is a 
massive consolidation with open bronchi, bronchial 
breathing will be present. 

2. Carcinoma Involving the Larger Bronchi. 
Physical Signs. — The physical signs present are largely 
those of the narrowing of the air passages. 

Inspection. — There is retraction of the lung with 
loss of motion over the affected area. Where the nar- 
rowing is very marked there may be sinking in of the 
chest during inspiration. 



222 THE RESPIRATORY SYSTEM. 

Palpation. — There is loss of vocal fremitus, and 
bronchial rhonchi may be detected. 

Percussion. — Loss of resonance, dullness with a 
slight tympanitic quality; thickening of the pleura 
causing the note to become almost flat. 

Auscultation. — There is loss of normal vesicular 
murmur, inspiration and expiration is accompanied by 
sibilant and sonorous rales of a peculiar whistling 
quality. 

3. Diffuse Carcinomatous Infiltration. — The 
physical signs are similar to those that occur in diffuse 
broncho-pneumonia, 

Differential Diagnosis. — Carcinoma involving 
the lower portion of the lung and pleura may give 
physical signs almost identical to pleurisy with effusion, 
and diagnosis can only be reached by the use of explora- 
tory puncture. When it involves the upper lobe of the 
lung and there is increased vocal fremitus, dullness and 
bronchial breathing, it may be mistaken for pneumonic 
consolidation. Absence of fever and the long continu- 
ance of the disease aids in the diagnosis. When the 
physical signs are flatness, diminished vocal fremitus 
and absence of bronchial breathing, it may be con- 
founded with interlobar pleurisy with effusion; here 
also the exploratory puncture may be necessary for diag- 
nosis. When the new growth causes pressure on a bron- 
chus, differential diagnosis is from aneurism and 
tumors developing in the mediastinum. In aneurism 
murmurs are present and there is pulsation of the chest 
wall. In malignant growth extending from the medias- 
tinum in addition to the respiratory symptoms there is 
more marked interference with the circulation. • 

PLEURISY. 

Pleurisy is an inflammation of the serous membrane, 
characterized by an exudation upon the free surface of 
the pleura, which may be fibrinous, serous, serofibrin- 
ous, sero^purulent, purulent or hemorrhagic. All 
these varieties of exudation may occur at different 



DISEASES OF RESPIRATORY TRACT. 223 

stages in the same case of pleurisy. The inflammation 
may not be attended with an exudation upon the free 
surface, but characterized by a fibrous thickening. 
Inflammations of the pleura may be acute or chronic, 
general or localized, primary or secondary. Numerous 
classifications or subdivisions of pleurisy have been 
made. For physical diagnosis three forms are suffi- 
cient, depending upon the character and amount of the 
exudation and the changes produced in the pleura : 
(1) Dry pleurisy with fibrinous exudate; (2) pleurisy 
with effusion, and (3) chronic pleurisy with adhesions. 

(1) Dry Pleurisy. — Before the exudation appears the 
pleural surface undergoes certain changes, which may 
give quite distinctive physical signs. The normal 
moist condition of the pleural surface is lacking. The 
surfaces become dry; there is loss of lining endothe- 
lium, with more or less roughening of the pleural sac. 
When exudation takes place the pleural surfaces are 
more or less thickly coated with fibrinous material, 
which, while allowing a certain amount of movement 
between the two pleural surfaces, causes thickening of 
the pleural sac and the occurrence of physical signs. 

(2) Pleurisy with Effusion. — This form includes sero- 
fibrinous pleurisy, subacute pleurisy, chronic pleurisy 
with effusion, empyema. The nature of the fluid does 
not modify the physical signs. The physical signs that 
are present with effusion into the pleural cavity are 
dependent upon the presence of the fluid and the effects 
that it produces upon the lung, heart, position of the 
diaphragm and abdominal viscera and in the thoracic 
walls. Normally the pleural surfaces are in apposition 
throughout. They are kept together by atmospheric 
pressure, although the elasticity of the lung on the one 
side and that of the thorax on the other produces a con- 
stant traction on the two pleural surfaces, which tends 
to separate them. When fluid or air is present in the 
pleural cavity, certain changes occur: (a) The two 
surfaces of the pleura are separated; (5) the distension 



224 THE RESPIRATORY SYSTEM. 

of the pleural sac diminishes the space to be filled by the 
lung; (c) the elasticity of the lung causes it to retract 
and to exert traction or lifting power on the fluid. 
Until a certain point is reached the fluid exercises no 
compressing action on the lung, which retracts before 
the fluid until its elasticity is satisfied. After this point 
has been reached the fluid causes compression of the 
lung, (d) With the filling in of the pleura there is loss. 
of tension in the pulmonary tissue, producing change in 
the percussion note, (e) The chest walls, relieved from 
the pulling action of the lung, assume the position of 
elastic equilibrium, changing the contour of that side 
of the thorax. The diaphragm, unacted upon by the 
lung, does not rise as high in the thorax; later on the 
weight of the fluid causes it to descend still lower. 
(f) The opposite lung is also influenced by the change 
in the intrathoracic pressure, and tends to contract and 
draw the heart and mediastinum towards the unaffected 
side, (g) Gradually, with the accumulation of fluid, 
the normal intrathoracic negative pressure diminishes 
to zero, and later may be replaced by positive pressure. 
As long as a negative pressure is present in the chest 
it exercises an action upon the fluid. As the fluid 
increases the negative pressure becomes less marked, 
and later the weight of the liquid itself exerts a positive 
pressure, causing bulging of the intercostal spaces, com- 
pression of the lung, depression of the diaphragm, dis- 
placement of the heart and interference with return 
circulation. As the negative pressure depends upon the 
elasticity of the lung, the occurrence of signs indicating 
change from negative to positive pressure is an index 
of the elasticity of the lung when taken in connection 
with amonnt of effusion. 

(3) Chronic Pleurisy with Adhesion. — In chronic 
pleurisy with adhesion, more or less fluid may be 
present, but usually the most marked pathological 
change is fibrous thickening of the pleura with adhe- 
sions, binding together the two surfaces of the sac. The 



DISEASES OF RESPIRATORY TRACT. 225 

effect of thickening of the pleura is to interfere with 
expansion of the lung and to prevent free movement of 
the thorax. When these changes are localized their 
effects are limited to the area involved, causing many 
of the thoracic deformities and interference with 
respiratory movements noted under "Inspection" and 
"Palpation." Thickening of the pleura, with imperfect 
expansion of the pulmonary tissue, causes change in the 
percussion note. As explained under "Auscultation," 
imperfect expansion of the lung causes diminution or 
absence of the normal breath sounds. Localized adhe- 
sive pleurisy occurs early in pulmonary tuberculosis, 
and modifies the physical signs of that condition. 

Physical Signs. Ixspectiox. 1. Dry Pleurisy. — 
When pain is present, the patient leans to the affected 
side, or lies on that side to prevent motion. Expansion 
is restricted, and motion is short and jerky. Movement 
over opposite lung is exaggerated. 

2. Pleurisy with Effusion. — When effusion, either 
fibrinous, serous or purulent, is sufficient to separate tho 
two surfaces, with absence of pain, motion over the 
affected side may be freer. With the occurrence of liquid 
effusion there is slight enlargement of the lower portion 
of the thorax. As the effusion increases the contour of 
the side becomes more rounded, with Avidening of the in- 
tercostal spaces. With complete filling of the pleural sac 
the side is enlarged in all directions. The spine is sli^iitlv 
curved toward the affected side; the intercostal spaces 
are obliterated, and the chest appears smooth. Motion 
becomes progressively less until, with full distension, it 
is absent. When positive pre-sure occurs within the 
pleural sac there is bulging of the intercostal spaces, 
and pulsations may be present. The opposite side is in 
a state of compensatory emphysema and the respiratory 
movements are exaggerated. Cardiac displacement 
occurs early unless prevented by adhesions or conditions 
causing fixation of the mediastinum. With absorption 
of the fluid, or with its withdrawal, the chest returns 
15 



226 THE RESPIRATORY SYSTEM. 

gradually to its normal contour, with increase of the 
respiratory movements. 

3. Pleurisy with Adhesion, — The occurrence of 
pleural thickening or adhesions causes movement to be 
restricted, followed by retraction of chest walls on the 
affected side if pulmonary expansion is prevented., 
These changes are especially marked over the base of the 

lung. 

Palpation. 1. Dry Pleurisy. — Vocal fremitus may 
be normal. When the fibrinous exudate is thick, vocal 
fremitus may be diminished or absent. Slight friction 
fremitus may be detected. 

2. Pleurisy with Effusion, — With the occurrence of 
effusion there is gradual loss of vocal fremitus, occur- 
ring first in the lower portion of the pleural sac pos- 
teriorly, and gradually advancing upward as the sac 
becomes filled. When the fluid has reached a certain 
amount, vocal fremitus is usually increased at the upper 
level. Vocal fremitus over the upper lobe of the lung 
may be normal. With extensive effusion, relaxation 
of the lung causes absence of vocal fremitus over the 
upper lobe also. Compression of the lung causes 
increased vocal fremitus posteriorly along the spine. 
Vocal fremitus may be detected over the site of the 
fluid when adhesions bind the lung to the chest wall 
and prevent its retraction. The degree of cardiac dis- 
placement may be estimated more definitely by palpa- 
tion than by inspection. Displacement of the liver 
below the free border of the ribs occurs when the 
effusion is large, or when retraction of the lung or loss 
of elasticity causes the fluid to act upon the diaphragm 

early. 

3. Pleurisy with Adhesion, — Pleuritic thickening, 
besides interfering with respiratory movements, causes 
diminution of vocal fremitus; and these, when asso- 
ciated with fibrous induration of the lung, may cause 
increased vocal fremitus. 

Pekcussion. 1. Dry Pleurisy.—Whh a slight 



DISEASES OF RESPIRATORY TRACT. 227 

fibrinous layer there is little or no change in resonance. 
If exudation is very abundant there is loss of resonance, 
with increased sense of resistance. 

2. Pleurisy with Effusion. — With the occurrence of 
effusion the earliest indications are shown by flatness 
at the base of the lung posteriorly. Slight effusion 
causes the area of flatness to be widest along the spine, 
sloping in a gentle curve toward the axilla. With in- 
crease of fluid the line of dullness extends beyond the 
axilla to the mammary line. When the fluid is sufficient 
to reach the angle of the scapula the percussion outline 
shows a more or less curved line, which has been called 
the "curved line of Ellis." 

The fluid rises highest in the axilla, and on the 
anterior border of the chest the line curves slightly 
downward toward the sternum, while posteriorly the 
line descends more abruptly to the spine. Percussion 
of the affected side at this stage shows three zones: 
(1) Flatness over the fluid; (2) posteriorly, dullness 
over the triangular space, bounded above by a line 
drawn horizontally from the apex of the line of flatness 
in the axilla. Above the horizontal line pulmonary 
resonance of low pitch, with faint tympanitic quality, 
may be detected. (3) On the anterior portion of the 
chest, between the horizontal line and the line of flat- 
ness, percussion gives a peculiar tympanitic quality — 
Skoda' s resonance. (Figs. 36 and 38.) 

As the fluid increases in amount and the elasticity of 
the lung is satisfied, the fluid assumes a more horizontal 
line, and at last, when negative pressure has been re- 
placed by positive (which generally occurs when the 
fluid reaches the level of the third rib), the lung is com- 
pressed by the fluid, and a small area of tympanitic 
percussion may be detected anteriorly under the clavi- 
cles, close to the sternum, and in the supraspinous fossa 
behind. 

As the curved outline of the fluid depends upon the 
elasticity of the lung, a more nearly horizontal line, 



228 



THE RESPIRATORY SYSTEM. 



with a small amount of effusion, shows that there is loss 
of pulmonary elasticity or that the lung is prevented 
from retracting by adhesions, or that there is consolida- 
tion (probably tubercular) at the apex. The position of 



Fig. 36. 




Lines 1, 2, 3, cur ye of small effusion. 

4, 5, 6, 7, curved line of Ellis (letter of S). 
Dotted line from summit of curve to spine, upper limit of dull 
triangle. 

the line of fluid does not change readily with change in 
posture of the patient. When the patient has long 
occupied the recumbent posture, the line of Ellis is more 
or less displaced by the fluid gravitating toward the most 



DISEASES OF RESPIRATORY TRACT. 



229 



dependent portion. The filling of one pleural sac causes 
displacement of the posterior mediastinum, giving a 
dull area known as Grocco's paravertebral triangle. 
Grocco's triangle is an area of relative dullness and 
diminution of respiratory murmur, found at the back of 



Fig. 37. 




Displacement of heart and mediastinum to the right by effusion into 

left pleural sac. Broken line shows level of fluid and position 

of heart after removal of 76 ounces. 

X-Ray tracing. 

the healthy side of a chest when there is pleural effusion 
on the other side. The superior angle of the triangle 
is situated on the spine, at about the level of the upper 
limit of the effusion ; its base is f omied by a line from 
one and a half to three inches in length, running along 
the lower border of the natural pulmonary resonance, 



230 



TEE RESPIRATORY SYSTEM. 



and its internal side is formed by the middle line of the 
back. Within this area the deficiency of resonance is 
greater the nearer one gets to the base and the inner 
side of the triangle. Kesonance returns when the fluid 
on the opposite side is removed by aspiration, or is ab- 
sorbed naturally, and it is lost again when the fluid 
reaccumulates. All these symptoms are more marked 

Fig. 38. 




Dotted line showing position of heart, according to amount of 

effusion. 

when the pleural effusion is on the right side than when 
it is on the left. They are caused by any kind of 
effusion, whether serous or purulent, and in lie absence 
of effusion they are not caused by tumor or by any vari- 
ety of pneumonia, or by plastic inflammation of the 
pleura. The importance of Greece's sign is that it fur- 
nishes an additional means of diagnosis between these 



DISEASES OF RESPIRATORY TRACT. 231 

diseases on the one hand and pleural effusion on the 

other. 

3. Pleurisy- with Adhesion. — Fibrous thickening of 
the pleura with adhesions causes the percussion note to 
be impaired over the lower portion of the lung, and is 
usually associated with retraction of the bony thorax. 

Auscultation. 1. Dry Pleurisy. — The respiratory 

Fig. 39. 




Posterior view of same case as Fig. 37. 

murmur is jerky and partly suppressed; inspiration is 
shortened, with expiration prolonged, slow and feeble. 
During the early stage the dry. rubbing friction sounds, 
similar to the sound made when two rough surfaces of 
paper are rubbed together, or when the hand is rubbed 
over the ear, are heard. With the occurrence of plastic 
exudation the character of the friction sounds change. 



232 THE RESPIRATORY SYSTEM. 

They become stickier, are superficial, and later may 
have a fine grazing character. They are most abundant 
at the end of inspiration and the beginning of expira- 
tion. They may be absent in quiet breathing, and only 
be detected at the end of a deep inspiration, When 
the pleurisy of the left side involves the portion over- 
lying the prsecordia, friction rales may be heard syn- 
chronously with the heart sounds. 

2. Pleurisy with Effusion. — The auscultatory signs 
are variable. The signs typical of effusion of small 
amount are slight diminution or absence of breath 
sounds at base of lung and distant voice sounds. As the 
fluid increases in amount, there is absence of breath 
sounds over the lower portion of the thorax correspond- 
ing to the line of percussion flatness. At the level 
of the fluid vesicular murmur may be faintly heard, 
associated with bronchial breathing of a peculiar blow- 
ing, wavy character. The voice sounds are also of a 
wavy, nasal character (segophony). At the upper por- 
tion of the thorax, over the apex of the lung, vesicular 
murmur may be normal or slightly exaggerated. In 
large effusions at the upper level, bronchial breathing 
becomes more intense, and bronchophony and pectoril- 
oquy are present. 

Occasionally tubular or bronchial breathing, broncho- 
phony and pectoriloquy are heard over the fluid, simu- 
lating the auscultatory signs heard in pneumonia. 
These signs are especially apt to occur in children ; also 
when bands of adhesion prevent the lung from retract- 
ing as the fluid accumulates, so that it is compressed 
posteriorly along the spine. The sound is conducted by 
the tense bands of adhesion through the fluid to the 
bony thorax. Small consolidation of the lower lobes of 
the lung may also cause bronchial breathing to be 
present below the level of the fluid. 

In addition to displacement of the heart, a soft, sys- 
tolic murmur is detected over the precordial space when 
the effusion is sufficiently large to cause pressure upon 



DISEASES OF RESPIRATORY TRACT. 233 

the mediastinum or slight distortion of the large vessels. 
With the disappearance of the fluid the breath sounds 
return, and pleuritic frictions are heard above the level 
of the fluid. 

Baccellis Sign. — Baccelli claimed that the whispered 
voice was conducted much better through a homogeneous 
serous fluid than purulent collections in the pleural 
cavity and was both felt and heard more distinctly in 
pleurisy with serous effusion than in empyema. The 
sign is untrustworthy, and depends more on the condi- 
tion of the underlying lung than on the nature of the 
effusion. 

3. Pleurisy with Adhesion. — Pleuritic thickening 
with adhesion causes absence or diminution of the 
breath sounds, with friction fremitus of a rough, rasp- 
ing or creaking character. Intercurrent attacks of 
acute pleurisy may reinduce the signs of fibrinous 
exudation and of effusion. 

Differential Diagnosis. Pleurodynia. — Inspection and 
palpation may be identical. Percussion shows no 
change in resonance. On auscultation there are present 
feeble breath sounds, due to loss of expansion of the 
thorax, but unattended with friction rales. 

Hydatid of the Pleura. — This may begin at the base 
of the lung, but rarely gives a line of dullness so 
symmetrical as that of pleurisy with effusion. Usually 
the area of percussion flatness is more nearly circular, 
with resonance on either side, which may have a more 
or less tympanitic quality. Displacement of the heart 
and abdominal viscera does not occur unless the cvst is 
lar^e. Over the cvst localized bulaino; of the chest wall 
is very marked. The differential diagnosis by physical 
signs between encapsulated pleurisy and hydatid cyst 
is almost impossible. 

Pneumonia. (See page 183.) 

Sub-Diaphragmatic Abscess. Inspection. — Change in 
the size and contour of the chest is most marked over the 
free ribs extending to the hypochondrium. 



234 THE RESPIRATORY SYSTEM. 

Palpation. — Absence of vocal fremitus over lower 
portion of thorax, associated with rigidity of hypochon- 
driac region and marked depression of liver. 

Percussion. — Upper line of flatness is high in axilla, 
but does not conform to that of pleurisy with effusion at 
the same level. Absence of dull area behind. Skoda' s 
resonance may be detected anteriorly. Displacement of 
the heart does not occur. Slight displacement upward 
of the diaphragm, with the apex of the diaphragm 
higher than normal. On examination with the X-ray 
the difference between subdiaphragmatic and supra- 
diaphragmatic conditions is well marked. 

HYDROTHORAX. 

This condition differs from pleurisy with effusion in 
that it is not inflammatory, but due to simple dropsi- 
cal effusion into the pleural cavity. When limited to 
one side the physical signs are identical with those of 
the inflammatory type. Usually both sides are involved, 
and the following physical signs are present : 

Inspection. — Slight motion on both sides. Slight 
enlargement over lower portion of thorax. 

Palpation. — Yocal fremitus is most marked poste- 
riorly. Heart is displaced upward. 

Percussion. — Flatness over lower portion of thorax. 
Line of flatness does not follow markedly the curve 
noted under unilateral affections. Above the level of 
the fluid Skoda' s resonance is early present, with hyper- 
resonance at the apex. 

Auscultation. — Absence of breath sounds at the 
base, below the level of the fluid. Bronchial breathing 
at the upper level. Pine, moist rales are heard over the 
rest of the lungs if pulmonary oedema is present. 

PNEUMOTHORAX. HYDRO-PNEUMOTHORAX. 

Due to the presence of air or air and fluid in the 
pleural cavity. 



DISEASES OF RESPIRATORY TRACT. 235 

Physical Signs. Inspection. — Enlargement more 
marked than in pleurisy with effusion. Loss of motion 
complete. 

Palpation. — Absence of vocal fremitus. In hydro- 
or pyo-pneumothorax succussion fremitus (splashing 
sounds) is present when the patient is shaken or on 
violent coughing. 

Percussion. — Pneumothorax ; increased resonance 
over affected side. When fluid and air are present in 
the pleural cavity two zones of resonance are detected — 
flatness below the level of the fluid, and increased reso- 
nance with a tympanitic quality above it. The line of 
flatness is horizontal. When the anterior portion of the 
chest is percussed with two coins or is snapped by finger 
while the observer listens behind, a peculiar ringing, 
metallic sound is heard (coin test.) (See page 149.) 

Auscultation. — In pneumothorax there may be 
absence of all respiratory sounds over the affected side. 
When an opening exists between the bronchial tract and 
pleural cavity a peculiar, intense, amphoric breathing 
is heard (lung fistula sound). When fluid and air are 
both contained in the pleural cavity, by shaking the 
patient, or after coughing, succussion sounds are pro- 
duced. The falling of drops of secretion from the 
upper portion of the cavity into the fluid below gives a 
peculiar echo-like sound (metallic tinkles). 



PART III. 
THE CIRCULATORY SYSTEM. 



CHAPTER VIII. 

INSPECTION. 



Inspection of the circulatory system embraces not 
only the heart, but also all of those phenomena that 
depend upon cardiac action. It includes the contour of 
the precordial area, the visible cardiac movements as 
shown by the apex beat, the pulsations of the arterial 
and venous systems, respiratory movements (dyspnoea), 
color of the skin and mucous membrane, and oedema of 
the cellular tissue. 

For examination, the patient's clothing should be 
removed, so that a free view of the anterior portion, at 
least of the chest, may be obtained. The patient should 
be examined in both direct and oblique light, and in the 
standing and recumbent postures. The examiner 
should view the surface from directly in front and after- 
wards obliquely, so as to note all cardiac movements. 

The circulatory movements may be seen more 
clearly by placing over the seat of motion a piece of 
adhesive 'plaster through which a pin has been stuck, 
and applying to this pin a piece of cotton or lint as a 
flag, or small cones of paper or bits of cotton wool 
may be stuck to the chest wall with mucilage or oint- 
ment. The object of this is to increase the area of 
motion as seen at the extremity of the pin or paper cone, 
and to determine whether or not the movement is 
expansile. This latter condition is best seen by placing 



238 THE CIRCULATORY SYSTEM. 

over the area of pulsation a piece of rubber plaster with 
a slit cut through it ; this will show increase in size by 
widening: of the opening. 

Data obtained by inspection must be verified and cor- 
rected by the knowledge obtained by the other methods 
of examination. 

Normally, that portion of the thorax which is known 
as the prsecordia shows a slight flattening surrounded by 
a slight elevation of the ribs. 

In the fifth intercostal space, 2% to 3 inches to the 
left of the sternum, at a point where a line drawn 2 
inches from the left edge of the sternum and 1 inch 
inside the nipple line bisects the space, is seen a local- 
ized, rhythmical impulse occupying an area of about 
1 inch square. 

THE APEX BEAT. 

This is due to the impact of the heart against the 
chest wall. It does not mark, as is commonly supposed, 
the true anatomical apex, for that part which strikes 
the chest wall is distant from the true apex about three- 
quarters of an inch. 

The cardiac impulse is due to change in form of the 
heart during systole, the vertical diameter being length- 
ened, with a corresponding shortening of the transverse. 

The site of the apex beat varies normally within cer- 
tain limits. In the child it is higher, being found in the 
fourth interspace, and farther from the mediastinum. 
In old age it is lower down, being in the sixth inter- 
space, nearer the median line. In persons with short, 
broad thoraces it is found slightly above the fifth inter- 
space, while in those in whom the thorax is narrow it 
may be found underneath the sixth rib, and even at the 
upper border of the sixth interspace. The site of the 
apex beat also varies with the position of the patient. 
When lying on the left side, it is carried to the left as 
far as the midclavicular line, and even farther; when 
the patient is lying on the right side, it is carried inward 



INSPECTION. 239 

toward the sternum, but its mobility is not as much 
as when the patient is lying on the left side. The respi- 
ratory act also causes a slight change in the location 
of the apex beat. In quiet respirations it is but little 
changed. In forced inspiration it is carried downward 
and toward the median line, while in forced expiration 
it is displaced upward and slightly to the left. 

Changes in the Praecordia. — The bony thorax over the 
cardiac area may bulge from the third to the seventh rib, 
and from the sternum to the left nipple ; or the projec- 
tion may extend from nipple to nipple. The bulging 
and distortion of the precordial area may be caused by 
conditions not associated with cardiac or circulatory dis- 
eases: (a) Swelling of the cellular tissue, due to 
inflammatory exudation or to localized deposits of 
adipose tissue; (b) changes in the bony thorax de- 
pendent upon rickets ; ( c) a bulging anteriorly, with a 
compensating posterior curve from spinal curvature. 

Local bulgings over the praecordia may be ceused 
by cardiac changes, although they are not marked unless 
the cardiac disease occurred in early life, when the 
flexibility of the bones permitted distortion, (a) Car- 
diac hypertrophy and dilatation do not produce marked 
change in the precordial area unless it has occurred 
early in life, when it may produce a distinct forward 
bulging of the sternum and ribs, especially of the left 
side. Congenital cardiac disease produces the most 
marked distortion of the thorax. The amount of de- 
formity in the case of chronic hypertrophy with dila- 
tation is important in estimating the time of life at 
which the cardiac disease occurred, (b) Pericarditis 
causes the contour of the praecordia to be rounded, the 
normal slight flatness being absent. The interspaces 
are wider than normal, being even with the surface of 
the ribs or bulging according to the amount of exuda- 
tion into the pericardial sac. The amount of bulging 
that is present in the case of pericarditis with effusion 
depends upon the flexibility of the bony thorax; it is 



240 THE CIRCULATORY SYSTEM. 

marked in childhood, and scarcely noticeable or absent 
when ossification of the ribs has taken place. 

Anenrism at different portions of the thoracic aorta 
may produce local bulgings, as will be described later. 

Permanent retraction of the bony thorax does not 
occur as the result of cardiac disease unless associated 
with other changes in the thoracic viscera. 

Conditions Modifying the Location, Extent and Character 
of the Apex Beat. — As has already been stated, the 
visible apex beat merely marks the point at which some 
portion of the heart, near the anatomical apex, strikes 
the chest wall. The portion of the heart which gives 
the impulse is generally the right ventricle, about three- 
quarters of an inch from the true apex. The point of 
contact of the heart may vary within wide limits, due to 
changes in the relation of the heart to the chest wall, so 
that the visible apex beat is changed from the normal in 
location, extent and character. 

Influence of the Soft Parts. — The apex beat is much 
more noticeable and the exact point of contact more 
distinct in thin persons, especially those with flexible 
thoraces. In persons where the prsecordia is thickly 
covered with adipose tissue the area of impulse will be 
slightly increased, while the point of the apex beat will 
be less distinct. This is especially marked in cases 
where the mamma is full and tense, the cardiac impulse 
being conveyed to the entire breast and the apex beat 
being masked. Where the mamma is large and flaccid, 
the apex beat may be entirely absent. 

Influence of the Bony Thorax. — The elasticity and 
mobility of the ribs influence largely the character of 
the apex beat. In children, where there is marked 
depression of the thorax during expiration, the apex 
beat is distinct and more extensive. In old age the 
rigidity of the thorax and secondary changes in the lung 
cause the apex to become indistinct or absent. Narrow 
intercostal spaces may render the apex beat invisible, 
the heart striking the chest immediately under the rib. 



INSPECTION. 241 

In very broad thoraces the apex beat is higher, being 
underneath the fifth rib, or even in the fourth inter- 
space. In long, narrow thoraces the apex beat is lower, 
being displaced downward and slightly outward. The 
flat, rachitic or paralytic thorax, with narrow antero- 
posterior diameter at the lower portion of the prsecor- 
dia, brings the apex beat further to the left in the 
fifth interspace. The pigeon-shaped thorax, with in- 
crease in the antero-posterior diameter, causes the apex 
beat to be nearer the median line and somewhat indis- 
tinct, except where the depression beyond the bulging 
causes the true apex to strike the chest wall. 

When the ribs over the cardiac region are displaced 
by primary disease of the lungs, the apex beat is dis- 
placed to the right or left and upwards or downward, 
according to the pulmonary condition. 

Influence of Diseases of the Pleura. — Filling of the 
pleural sac with air or fluid causes displacement of the 
heart to the opposite side and alters its relation to the 
chest wall, unless the movement of the heart is prevented 
by adhesions. 

Effusions into the right pleural sac cause the heart to 
be displaced to the left and upward, the apex beat being 
seen in the mid-axillary line. The base of the heart is 
also displaced, but not to the same degree as the apex. 

Effusions into the left pleural sac move the heart 
toward the right, so that, according to the amount of 
fluid present, the apex beat may be felt at any point 
between the normal site and the right mammillary line. 
(Fig. 36.) As was noted under "Pleurisy with Effu- 
sion" (page 225), displacement of the heart is one of the 
most characteristic signs of this condition. Occasion- 
ally the cardiac impulse is transmitted to the fluid, 
giving the physical signs of pulsating empyema. 

Adhesions of the pleural surface and contractions 
draw the heart toward the affected side, with displace- 
ment of the apex beat. This will be fully explained 
later on. 

16 



242 THE CIRCULATORY SYSTEM. 

Influence of Changes in the Lung. — Quiet breathing 
produces no change in the apex beat. Full, deep in- 
spiration causes the inflated lung to cover the heart to a 
greater degree, thus lessening the extent and force of 
the apex beat, and may cause it to disappear entirely. 
Frequently it is sufficient to displace it downward, so 
that it is seen an interspace lower. 

Permanent increase in size of the lungs, as in general 
emphysema, causes marked change in the relation of the 
heart to the bony thorax. As a result of the increase in 
size of the lungs and loss of tension, as was explained 
under "Emphysema," there is elevation of the ribs and 
depression of the diaphragm, which also depresses the 
heart, the apex beat being carried inward and down- 
ward. When increase in size of the lung is associated 
with obstruction of the circulation, the hypertrophy and 
dilatation of the right ventricle increase the pulsation in 
area and extent, and carry it still lower, giving epigastric 

pulsation. 

Unilateral emphysema causes the heart to be dis- 
placed similarly to that which occurs in pleurisy. Com- 
pensatory emphysema in the right lung carries the apex 
beat to the left and higher. Emphysema of the left 
lnng causes it to be lower, and rarely displaces it beyond 
the left sternal line. 

Shrinkage of the lung as a result of pleurisy, or due 
to interstitial change in the pulmonary tissue (as in 
interstitial pneumonia and fibroid phthisis), draws the 
heart toward the diseased side. When the changes are 
limited to the lower border of the left lung, that portion 
of the heart which is normally covered by pulmonary 
tissue may be brought into direct contact with the chest 
wall ; the visible apex beat will be increased in area and 
carried horizontally to the left, and a greater portion of 
the" heart, including the true apex, strikes the chest wall. 
When the change is more extensive, the heart may be 
drawn upward and outward, the apex beat being seen in 
the mid-axillary line. When the right lung is affected 



INSPECTION. 243 

the heart is drawn to the right side and upward. In- 
volvement of the upper portion of the lung may cause 
visible pulsations of the pulmonary artery in the second 
left interspace, or it may be so extensive that the phases 
of cardiac movement, systole, diastole and the pre- 
systolic contraction of the auricle mav be seen over the 
entire precordial space, giving the impression of a 
peristaltic wave. 

Influence of Changes in the Pericardium. — Effusion into 
the pericardium causes change in the site and area of 
the apex beat, according to the character and amount of 
exudation. In small effusions the apex beat may be 
seen over a wider area, especially toward the epigas- 
trium. When the pericardium is filled to a greater 
degree the visible apex beat is carried upward into the 
fourth interspace or higher, due to a portion of the heart 
higher up striking the chest wall, and not to an upward 
displacement of the true apex. When the pericardium 
is fully distended with fluid the apex beat may be 
absent. 

Adhesions of the pericardium to the pleura or medias- 
tinum may cause retraction of the chest wall over the 
apex (Broadbent's sign). Eetraction of the chest wall 
over the precordial area is one of the diagnostic signs of 
adhesions of the pericardium when it produces marked 
visible recession of the costal cartilages, ribs and 
sternum, and is associated with signs of cardiac hyper- 
trophy greater than the amount of cardiac valvular dis- 
ease would produce, and where there is also evidence of 
a co-existing pleurisy or exo-cardial disease. 

Retraction of the chest wall over the apex also occurs 
with adherent pericardium, secondary to pulmonary 
tuberculosis. 

Influence of Changes in the Heart. — The site, extent 
and character of the apex beat corresponds, within cer- 
tain limits, to the extent of the cardiac changes. Power- 
ful action of the heart, due to physical exertion or 
mental excitement, as in Grave's disease, in poisoning 



244 THE CIRCULATORY SYSTEM. 

and in fever, causes the apex beat to be more noticeable 
and broader by causing a larger area of the chest wall 

to be affected. 

In a similar manner, simple hypertrophy of the leit 
ventricle causes the apex beat to be carried to the left 
and very slightly downward. Increase in the size and 
force of the left ventricle causes a portion of the heart 
closer to the true apex to strike the chest wall, and the 
beat is strong, distinct and defined. When the left 
ventricle is both dilated and hypertrophied, the apex 
beat is carried downward and to the left, and may be seen 
in the eighth interspace or lower. The impulse is in pro- 
portion to the amount of hypertrophy; the apex beat 
will be correspondingly strong, a larger area of the chest 
wall will be influenced and the impulse, though wide, 

will be well defined. 

When dilatation is the most marked feature the apex 
beat will be weak and diffused. < 

Eight-sided cardiac hypertrophy causes the visible 
pulsation to appear between the ensiform cartilage and 
the normal position of the apex beat in the fifth inter- 
space. The apex beat may be carried slightly to the 
left, but rarely goes beyond the left mammary line. 
When the hypertrophy of the right ventricle is extensive 
and associated with dilatation, pulsations may be seen m 
the third, fourth, fifth, sixth and even seventh inter- 
space near the termination of the cartilages on the left 
side of the sternum, or in the epigastrium, along the 
free border of the ribs on the left side. 

When dilatation of the right ventricle is extensive, 
with slight hypertrophy, the area of pulsation is mor« 
extended, and the character of the impulse is more 

diffused. . 

Dilatation of the right auricle may cause pulsation 
to be seen in the fifth right interspace along the stenmm 
Pulsation of the conus arteriosus and hypertrophy and 
dilatation of the right ventricle may produce pulsations 
in the second and third interspaces on. the left side. 



INSPECTION. 245 

Cardiac weakness from any cause, as myocarditis, 
fatty heart, degenerations, etc., causes the apex beat to 
be less noticeable or entirely absent. 

In congenital transpositions of the organs the apex 
beat is found to the right side of the fifth interspace, 
and has the characteristics of that noted in the normal 
position. 

Influence of Changes in the Mediastinum. — Aneurism of 
that portion of the aorta contained in the mediastinum, 
abscesses, new growths and enlarged glands displace the. 
apex beat downward and to the left. Adhesive medias- 
tinals with contraction may bind the heart down and 
cause retraction of the precordial area during systole. 

Influence of Abdominal Changes. — Pressure from below 
the diaphragm, due to ascites, meteorism, tumors or 
anything that increases the contents or the abdominal 
pressure forces up the diaphragm, causing the heart to 
be displaced upward and the apex beat to be seen in the 
fourth interspace to the left. 

Displacement of the diaphragm downward, as occurs 
in ptosis of the abdominal organs, etc., carries the apex 
downward, and the impulse is seen in the epigastric 
region only. 

IMPULSES DUE TO CHANGES IN BLOOD-VESSELS. 

Aneurism of the thoracic aorta may produce visible 
pulsations in different portions of the thorax. When it 
involves the ascending portion the pulsation is seen to 
the right of the sternum. When the transverse portion 
is involved the impulse may be conveyed to the sternum 
. itself and upward, and be seen also in the episternal 
notch. Aneurism of the descending aorta, when devel- 
oping forward, shows the impulse to the left of the 
sternum. 

Arterial Pulsations.- — Normally, the only pulsation that 
is seen in the arteries is a slight movement in the caro- 
tids just above the clavicles. 



246 THE CIRCULATORY SYSTEM. 

Conditions Causing Visible Pulsations in the Arteries. 
(1) Cardiac Causes. — When cardiac action is sudden 
and forcible, as occurs in exercise and under mental 
excitement, the blood is forced into the aorta and larger 
blood-vessels with sufficient force to cause a marked 
visible pulsation. 

(2) Vascular Causes. — When the blood is forced 
from the heart into the blood-vessels that are only par- 
tially filled, instead of the normal pulse wave being 
transmitted through the blood-vessels there is a direct 
propulsion of the blood wave through the aorta into the 
blood-vessels themselves. This condition of the blood- 
vessels occurs (a) whenever there is a rapid emptying of 
the larger blood-vessels into the capillaries and veins, as 
occurs in vaso-motor loss of control, in Grave's disease, 
chlorosis and ansemia ; (b) when the aorta, during dias- 
tole, empties itself into the enlarged ventricle (aortic 
regurgitation), and with the following systole there is a 
sudden forcing of a large amount of blood into the par- 
tially empty and collapsed aorta and its branches. In 
aortic regurgitation the visible systolic pulsation may 
be seen over the entire body, (c) Arterial pulsation is 
also seen when the blood-vessels have been converted 
from elastic, distensible tubes into rigid ones. Xor- 
mallv, with each svstole there is dilatation of the aorta, 
and during diastole the elasticity of the large vessels 
forces the blood onward. ^ lien the aorta is converted 
into a rigid tube, with each systole the heart impulse is 
conveyed to the entire arterial tract, producing visible 
movement in the blood-vessels. 

Capillary Pulse. — Occasionally in aortic regurgitation 
systolic, rhythmical pulsations are seen in the capil- 
laries; with loss of cardiac power these pulsations dis- 
appear. Capillary pulse may be observed by friction of 
the surface, producing dilatation of the superficial blood- 
vessels, or by placing a slide on the mucous membrane 
of the lips and with slight pressure causing the capil- 
laries alone to be seen. 



INSPECTION. 247 

Venous Pulsation. — Slight pulsations may be seen in 
the neck during health, but are most marked in the 
subjects of chlorosis and anaemia. In order to see them 
the patient should be recumbent, the head thrown 
slightly backward and the light should fall across the 
root of the neck obliquely. The physician should view 
the neck at a slightly higher level. 

The normal venous pulsations are usually a gradual, 
general dilation of the blood-vessel. "The wave is 
longer, broader and less sudden in its oscillation than 
that seen in the artery. It is more influenced by 
posture, being greatest when the patient is lying flat. It 
is presystolic, occurring before that of the carotid ; the 
collapse of the vein corresponds to the apex beat.' : In 
chlorosis and anaemia this presystolic venous pulsation 
may be markedly increased. 

The abnormal pulsations seen in the veins are systolic 
in time. They are most marked in the veins of the right 
side, and should be looked for in the external jugulars 
just above the clavicle, outside of the border of the ster- 
nocleidomastoid muscle, as at this point the vein is unac- 
companied by the artery. 

It is necessary to determine whether or not the sys- 
tolic pulsation in the vein is due to the impulse con- 
veyed to the vein from a distance. (1) If slight, grad- 
ual pressure over the vein at the lowest point stops the 
pulsation it shows that it is a true venous pulsation. 
Such a light pressure would not influence pulsations 
transmitted from the artery. (2) By drawing the finger 
upward along the course of the vein, and keeping it at the 
upper level, the vein will fill from below and the pulsa- 
tion will be systolic. Sudden emptying of the vein dur- 
ing diastole is said to be a sign of adherent pericardium, 
but is a sign of doubtful value. 

Pulsation in the peripheral veins may be due (a) to 
aortic regurgitation; (b) certain stages of fever, and 
is made more visible by putting a thin layer of sealing 
wax over the vein. 



248 THE CIRCULATORY SYSTEM. 

Cardiac Dyspnoea. — Cardiac dyspnoea differs from pul- 
monary dyspnoea in the following respects: (1) While 
the patient is at rest the respiratory movements are 
normal, but the slightest exertion induces an intense 
feeling of oppression and dyspnoea. (2) Examination 
of the lung shows no interference with the entrance or 
exit of air; respiratory movements are increased in 
force, frequency and extent without the other evidences 
of interference in the respiratory tract. (3) The 
dyspnoea is out of all proportion to the lesion that may 
have been induced secondarily in the lung by the cardiac 

disease. 

Types of Cardiac Dyspepsia. — (1) Dyspnoea on ex- 
ertion, (2) paroxysmal dyspnoea, occurring when at 
rest, especially when the patient wakes out of sleep, due 
to sudden raising of the blood pressure; (3) chronic 
dyspnoea or orthopnoea, (4) rhythmical dyspnoea 
( Cheyne-Stokes respiration) . 

Dropsy. — (Edema due to cardiac disease appears first 
over the dorsum of the feet and at ankles and skin over 
the lower portion of the tibia. As interference with the 
circulation becomes more marked the dropsy ascends 
from below upward, involving the thighs, abdomen and 
finally becomes general (anasarca), when the serous 
cavities become involved. 

(Edema due to renal causes appears first in the face, 
and soon becomes general. In anaemia the dropsy first 
develops in the more dependent parts of the body, and 
in this respect resembles that of cardiac disease. 



CHAPTEE IX. 

PALPATION. 

Palpation not only corroborates the data obtained 
by inspection, but also corrects it, and gives additional 
and more exact information concerning the changes in 
the prsecordia and their causes. 1 1 enlarges the knowl- 
edge of cardiac movements by detecting pulsations too 
feeble to be noticed by the eye, and shows not only the 
position of the apex beat, but also its extent, force, char- 
acter and rhythm. 

While inspection gives us the point at which some por- 
tion of the heart strikes the chest Avail, by palpation 
we are able to fix the position of the anatomical apex, 
and it is thus possible to determine the true size of the 

lie art. 

It is especially valuable to determine whether pulsa- 
tions are systolic, diastolic, irregular or intermittent, 
and to detect other vibratory phenomena, as fremitus 

and thrills. 

In order to obtain the most satisfactory results from 
palpation it is necessary that the patient assume an easy 
position, whether it be standing, sitting or reclining. 
When feasible the patient should be examined in more 
than one position, as posture has a marked influence on 
the position and force of the cardiac impulse. The 
observer should place his hand lightly over the lower 
portion of the pra-cordia and note the general character 
of the sensation conveyed to it. Then, by the tips of the 
fingers, the exact location of the maximum apex beat 
may be determined. Frequently, when the pulsations 
are" indistinct or diffuse, it is difficult to locate exactly 
the point of maximum intensity of the apex beat. In 
such cases it is best to apply the tips of the fingers to 



250 THE CIRCULATORY SYSTEM. 

the thorax beyond the point of visible pulsation, and, 
moving them along the interspaces, locate the point at 
which the elevating impulse is felt most distinctly. 

Palpation enlarges the knowledge obtained by inspec- 
tion of increase in size of the prrecordia by determining 
whether or not the enlargement is due to oedema, inflam- 
matory swelling, or new growths of the soft parts. In 
regard to the bony thorax it determines the degree to 
which it is influenced by each cardiac beat. 

The cardiac movement is felt by the hand placed over 
the prsecordia in the region of the apex, in an adult with 
fairly thin chest walls, as a diffused throb, which at the 
fifth intercostal space ends with a distinct elevating- 
impulse. The pulsation felt is synchronous with the 
visible apex beat and the carotid pulsation, and slightly 
precedes the radial pulse. In thin persons with flexible 
chest walls, a distinct, sharp jerk or shock may be felt 
at the base of the heart when the flat of the hand is 
applied. With the finger tips it can be localized in the 
third or fourth interspaces, close to the sternum. It is 
diastolic in time, due to the closure of the aortic and 
pulmonary valves (valve shock). In its most perfect 
manifestation, cardiac impulse is felt as a distinct 
movement or peristaltic wave passing from apex to base. 

The apex beat varies normally in its point of maxi- 
mum intensity, force and extent, as has already been 
described under "Inspection." 

Conditions Modifying the Apex Beat. — The influence of 
posture on the position of the heart is much more notice- 
able by palpation than by inspection, and must always 
be taken into account. When the patient is standing, 
bending forward causes the cardiac impulse to become 
more distinct and sustained. In many cases the apex 
beat can only be located with the patient in this position. 
When in the semi-recumbent position or lying flat upon 
the back, the heart recedes from the chest wall, and the 
impulse becomes correspondingly weak and indistinct. 
When lying on the left side the heart is displaced 



PALPATION. 251 

toward the same side, and is felt about midway between 
its normal position and the anterior axillary line ; and 
the apex impulse is not so marked, being covered to a 
greater extent by lung tissue. When lying on the right 
side the heart is carried toward the right, and the apex 
beat is felt nearer to the sternum, or it may be under the 
sternum, and the impulse will be faint or entirely 
absent. When the heart is carried under the sternum 
the beat may be sometimes felt as a diffused, weak epi- 
gastric impulse. 

The position of the apex beat varies with age, as has 
already been explained. During the first two years of 
life it is visible in the fourth interspace, but palpation 
shows that the true apex is near or to the left of the 
nipple line. From the second until the sixth year it 
gradually assumes a position nearer to the median line 
and lower, until after the sixth year it is found in the 
fifth interspace. In childhood the force of the beat is 
relatively greater, on account of the flexibility of the 
ribs and the condition of the lungs. In old age the 
heart is displaced downward and toward the median 
line, and the apex beat is stronger on account of senile 
hvpertrophy. 

" Influence of the Soft Parts.— Marked increase in the 
thickness of the thoracic wall has but a slight effect upon 
the palpable apex beat, as by firm pressure we are able 
to render the tissues in such a condition as to readily 
convey the impulse. 

Influence of the Bony Thorax. — In young subjects, with 
thin, elastic ribs, the cardiac impulse is sufficient to 
be felt as a lift or elevating sensation, not only in the 
intercostal spaces, but also over the ribs, the point of 
maximum intensity of the apex beat being much more 
distinct and less diffused than in the adult. Where the 
bony structures are rigid the cardiac impulse influences 
the bony thorax but slightly, and the apex beat is only 
felt in the intercostal spaces ; in other portions of ^ the 
thorax it is more the sensation of a jar. Deformities 



252 TEE CIRCULATORY SYSTEM. 

of the spine readily give rise to displacement of the apex 
beat. In a shallow chest the heart lies more closely to 
the anterior wall, and the apex beat is more diffuse and 
stronger. In chests where the anterio-posterior diameter 
is increased from curvature of the spine the reverse con- 
dition is present. Even a mild degree of scoliosis may 
markedly influence the heart's position, in some cases 
simulating hypertrophy of the left ventricle. 

Influence of Changes in the Pleura. — Filling of the 
pleural sac with air or fluid, in addition to displacing 
the apex beat, changes the character of the impulse. 
The relation of the heart to the chest wall being altered, 
the impulse is feebler and more diffused. Occasionally 
pulsations from the heart are conveyed to the fluid in 
the pleural cavity and transmitted over the entire 
thorax. This is more likely to occur when the fluid is 
purulent (pulsating empyema). 

Contraction of the left pleura causes the heart to be 
uncovered, and a larger area to be brought in contact 
with the chest wall. The apex beat is not only carried 
to the left, but it is also more visible and of a wider 
extent. When the same change occurs in the right 
pleura the impulse may be felt to the right of the ster- 
num. When the pleural surfaces are covered with thick, 
tenacious exudate, as in acute pleurisy, cardiac move- 
ment may cause friction fremitus to be felt with each 
beat, or only when the cardiac systole coincides with full 
inspiration or expiration. It is sometimes difficult to 
determine whether the fremitus which is felt is pro- 
duced in the pleura or in the pericardium. If produced 
in the pleura it does not occur if the patient holds his 
breath. The exception to this rule occurs when adhe- 
sions have taken place between the pericardium and the 
pleural surfaces. 

Influence of Changes in the Lung Tissue. — The effect of 
lung changes upon the position of the apex beat has 
already been noted. Retraction of the left lung causes 
the apex beat to become more extensive; retraction of 



PALPATION. 253 

the right lung may cause displacement of the apex beat, 
with a more diffused and weaker impulse. 

General emphysema, in addition to changing the posi- 
tion of the heart and apex beat, is also apt to induce 
changes in the heart itself, causing the apex beat to 
become more feeble and diffused. In unilateral emphy- 
sema the apex beat is not only displaced by the enlarged 
lung, but, as this condition is usually associated with a 
corresponding diminution of the other lung, there is apt 
to be some change in the heart itself which modifies the 
character of the apex beat. 

Influence of Changes in the Pericardium. — Effusions 
into the pericardium cause not only elevation of the 
visible apex, but the intervention between the heart and 
the chest wall of a layer of fluid causes the beat to 
become less distinct, and at the same time somewhat dif- 
fused. As the effusion increases in amount the pulsa- 
tion felt over the lower portion of the prsecordia is a 
peculiar, wave-like sensation, while over the site of the 
visible apex beat there is felt a weak, elevating impulse. 
In extreme effusion the only impulse noticed may be a 
diffuse sensation of fluctuation. When the pericardium 
is covered by thick, tenacious (plastic) exudate, a fric- 
tion fremitus may be felt over the entire prrecordia, 
but most frequently it is limited to that portion of the 
pericardium that is not covered by lung tissue, and 
which corresponds to the area of absolute dullness on 
percussion. It may be detected by light pressure over 
the pra?cordia, and can be intensified by causing the 
patient to lean forward and making firm pressure in the 
interspaces. The fremitus occurs rhythmically with 
the cardiac action. 

Influence of Cardiac Changes. — As the palpable impulse 
is due to the impact of the heart on the chest wall, it 
will vary according to the muscular power and size of 
the heart. In the normal heart it is increased by those 
causes which produce overaction, as nervous excitement, 
pyrexia, toxic agents, exertion and • irritability of the 



254 TEE CIRCULATORY SYSTEM. 

heart muscle due to a beginning inflammation of the 
pericardium or endocardium. These factors wil] 
merely cause increase in the force of the apex beat, 
without change in its location. Hypertrophy of the 
heart modifies the character of the apex beat according 
to which portion of the organ is affected. Hypertrophy 
of the left ventricle causes the pulsation to be strong, 
prolonged and heaving or thrusting in character. The 
apex beat is well defined, and the lifting impulse, while 
marked, is not sudden. When hypertrophy and dilata- 
tion of the left ventricle are associated, not only is the 
apex beat carried downward and to the left, being fre- 
quently felt in the mid-axillary line, but the impact may 
be powerful enough to influence the entire left chest, and 
is felt as a lifting, heaving motion. 

When dilatation of the left ventricle is the most 
prominent feature, there being relative muscular weak- 
ness, although hypertrophy is present, the impulse is 
weak and abrupt, and the apex beat is ill-defined and 
diffused. The lifting sensation of the normal apex 
beat is wanting in simple dilatation of muscular weak- 
ness or degeneration. 

As normally the apex beat is due to some portion of 
the right ventricle striking the chest wall, in hyper- 
trophy of the right ventricle this area is increased and 
carried toward the median line, and the sensation felt 
by the hand is of a diffused lifting character, which is 
visibly transmitted to the epigastrium and the lower 
portion of the sternum. When dilatation and hyper- 
trophy are associated the impulse becomes more dif- 
fused. In marked dilatation with muscular weakness, 
the impulse is of a wave-like, indistinct character, and 
mav be felt to the riffht of the sternum. 

Palpable Vibrations, or Thrills. 

Normally, the blood passes through the cardiac orifices 
without being thrown into vibration, but when the 
smooth surfaces of these orifices are roughened or nar- 



PALPATION. 255 

rowed, when the valves become insufficient to close them, 
or when the blood is reduced in specific gravity, vibra- 
tions may be produced in the blood stream of sufficient 
intensity to be conveyed to the surface and to be detected 
by the hand as a thrill, which has been compared to that 
felt over the back of a purring cat (fremissement cataire, 
Katzenschnurren) . 

As the thrills always depend on the movement of 
blood through a cardiac orifice, it is necessary to deter- 
mine (a) their location, (b) their area of diffusion and 
(c) their relation to the period of the cardiac cycle 
(time or rhythm), as they may be systolic, diastolic or 
pre-systolic. 

Over the apex of the heart the thrills may be due to 
mitral obstruction, mitral regurgitation, rarely to aortic 
obstruction and regurgitation. 

Thrills due to mitral obstruction are usually well 
defined and have a peculiar vibratory character, so that 
the term "purring thrill" has been given them. The 
point of maximum intensity is somewhat above and to 
the inner side of the apex. The area of diffusion is 
usually limited to that of the apex beat, although at 
times it may be carried beyond. They are felt just 
before the lifting impulse of the apex, by which they are 
usually terminated. As they occur during that portion 
of the diastole which immediately precedes the systole 
they are said to be pre-systolic. 

Thrills felt in mitral regurgitation are usually of a 
soft, indistinct character, felt chiefly over the area of 
the maximum apex beat and occurring at the time of the 
lifting impulse. 

Thrills at the apex, due to aortic obstruction or 
regurgitation, are usually faint in character, and their 
intensity increases as the hand passes upward over the 
prsecordia toward the base of the heart. 

Thrills felt over the upper portion of the chest may 
be produced at the aortic or the pulmonic orifices. 
While pulmonic obstruction and regurgitation may be 



256 THE CIRCULATORY SYSTEM. 

attended with vibrations sufficiently powerful to be felt 
at the surface as thrills, they are so extremely rare that 
they may practically be left out of consideration. 

Thrills produced by aortic obstruction have their 
point of maximum intensity at the second intercostal 
cartilage on the right side. They are transmitted up- 
ward, and occur synchronously with the apex beat and 
the carotid pulsation. The character of the thrill has 
nothing distinctive. 

Thrills occurring with aortic regurgitation have the 
point of maximum intensity at the second right costal 
cartilage or slightly below, and may be transmitted to 
the sternum or be felt over the entire precordial area. 

Palpation of the Blood-Vessels.— The heart, in connec- 
tion with the arterial and venous systems, constitutes the 
circulatory apparatus, and palpation of the heart would 
be incomplete and misleading for diagnosis if both 
arterial and venous systems were not included. 

Palpation of the Aorta.— Normally, the thoracic aorta 
is beyond the reach of the examining finger, except m a 
few cases where the finger pressed behind the sternum 
in the episternal notch detects a faint pulsation. In 
enlargement of the calibre of the aorta, as occurs m 
diffuse dilatation of the blood-vessel, secondary to valvu- 
lar disease of the heart, or dependent upon atheroma, or 
in aneurism, the aorta may be palpable not only above 
the clavicle and sternum, but also in the first and second 
intercostal spaces on either side of the sternum. 

In dilatation of the transverse portion of the aorta 
the pulsation of the blood-vessel may be transmitted to 
the upper portion of the sternum, and may be also 
accompanied by a thrill which is synchronous with the 

heart action. 

Aneurism of the ascending and transverse portions ot 
the aorta may communicate pulsations to the trachea 
and larynx, giving the tracheal tug. In order to obtain 
this sign the patient is placed in the erect position, 
standing or sitting, the mouth closed and the chm ele- 



PALPATION. 257 

vated to its fullest extent. The examiner grasps the 
cricoid cartilage between the thumb and finger, and 
makes gentle upward pressure. 

On account of the tendency of the innominate and 
carotid arteries to transmit a pulsation to the trachea, 
Evart has advised that the examination be made in the 
following manner: "The observer stands behind the 
seated patient, whose head is thrown back and sup- 
ported against the observer's chest. The tips of both 
index fingers are then inserted under the lower edge of 
the cricoid cartilage, which is gently raised by them." 
when a very distinct and unmistakable traction down- 
ward is felt' with each systole of the heart. In extreme 
aortic regurgitation slight pulsation may be felt in the 
trachea, but it lacks the peculiar dragging, tugging sen- 
sation. 

Tracheal tugging is only present when ''the aneurism 
is so situated that it presses from above downward upon 
the bronchi near their bifurcation, or upon that portion 
of the trachea just above it."' As an aneurism, to give 
such a pressure, must be given off from the posterior 
and inferior portions of the transverse division of the 
aorta, tracheal tugging is an early manifestation of dila- 
tation in these positions. 

THE PULSE. 

When an artery is palpated to obtain the pulse a 
portion is usually selected where the vessel can be com- 
pressed between the examining finger and a firm point, 
as a bony eminence. The temporal, facial or radial 
arteries may be selected as meeting this requirement. 
The radial vessel is preferred on account of the readi- 
ness of access, and also from the fact that its condi- 
tion is not readily disturbed bv disease of the structures 
which it supplies. 

In order to readily appreciate all the elements of the 
pulse it is necessary that a certain amount of the vessel 

17 



258 



TEE CIRCULATORY SYSTEM. 



be under observation. This is attained by the classical 
method of placing the tips of three fingers on the radial 
artery, the most sensitive and most highly educated 
index finger farthest from the heart, while the thumb 
supports the wrist at the back. Another is "that the 
patient's hand and forearm is supported by the exam- 
iner's left hand, while the forefinger of the right hand is 
applied longitudinally over the artery. In this way the 
vessel is felt over a considerable length of its course by 
one finger of the observer, and varying degrees of 

Fig. 40. 




Taking the pulse. (Musser) 

pressure can be applied to it, while the skin can be 
pushed up and the size of the artery and the character 
of the arterial coats can be determined." (Sanson.) 

The sensation that is felt when an artery is palpated 
is due to the momentary increase in arterial pressure 
that occurs when the left ventricle empties itself into the 
aorta. The pulse wave distends the vessel that has been 
partially empty during diastole, and whose lumen is 
still further narrowed by the examining finger. ; 'The 
pulse then indicates simply the degree of duration of the 



PALPATION. 259 

increased pressure in the arterial system caused by the 
ventricular systole." (Broadbent.) 

It is necessary to bear in mind that three factors are 
concerned in the production of the pulse: (1) Cardiac 
action, which determines (a) frequency (fast or slow), 
(b) force (strong or weak), (c) rhythm (regular, irreg- 
ular or intermittent). 

(2) The elasticity of the blood-vessel, upon which 
depends the degree of compressibility of the pulse (hard 
or firm, compressible or incompressible). 

(3) Resistance in the arterioles and capillaries, 
which determines the readiness with which the larger 
blood-vessels are emptied during the period of diastole 
and regulates (a) the size of the pulse; whether the 
excursion of the artery compressed by the finger is wide 
or narrow, when the pulse is spoken of as large or small ; 
(b) the duration of the time that the wave is perceptible 
to the touch, so that the pulse is long or short ; (c) ten- 
sion or the degree of distension of the blood-vessels 
present throughout the cardiac diastole, and especially 
near its end. 

Size, duration and tension are usually associated in 
a definite manner. Low resistance in the arterv and 
capillaries give a pulse of large size, short duration and 
low tension, while great interference causes the pulse to 
be small, long and of high tension. 

These three factors are more or less correlated and 
react on each other, and each exerts its own peculiar 
influence on the pulse, both in health and disease. 

The Normal Pulse — The normal pulse for the healthy 
adult male beats 72 times per minute (frequency) ; the 
strength of each distending impulse is the same (force), 
and the beats follow each other at regular intervals 
(rhythm). The lumen of the artery is readilv obliter- 
ated by the examining finger nearest the heart, and the 
pulse wave is stopped at the point of pressure, beyond 
which, distally, the artery cannot be detected as a sepa- 
rate structure. The pulse wave is felt as a dilating force 



260 TEE CIRCULATORY SYSTEM. 

of some volume (size), which does not raise the finger 
to the full height at once, but takes a definite time to 
reach its acme and declines in the same manner (dura- 
tion) ; and between the pulsations the artery is felt 
under the finger, and can be compressed with greater or 
less ease according to its degree of distension (tension). 
It is necessary to distinguish between the incompressi- 
bility of a blood-vessel clue to condition of its walls 
(rigidity) and the amount of pressure necessary to over- 
come the distension of the vessel clue to the blood 
pressure (tension). When the pulsations in the artery 
are obliterated with difficulty, if the incompressibility 
is due to increased thickness of the arterial coats the 
artery will be felt beyond the point of compression as a 




Sphygmographic tracing of normal pulse. 
a, h, percussion up-stroke ; a, ~b> c, percussion wave ; c, d, e, tidal wave ; 
e, f, g, dicrotic wave; d, e, f, aortic notch; f 3 g, diastolic period. 

more or less rigid cord ; while if the incompressibility is 
due to high arterial tension it will be impossible to 
detect the artery beyond the compressing finger. 

• While the above are the average characteristics, each 
pulse may present individual peculiarities in the three 
factors spoken of. Both radial arteries should be ex- 
amined, and when differences are detected it is neces- 
sary to determine whether they are due to anomaly in 
the size or distribution of the arteries, or are dependent 
upon pathological changes, as aneurisms, plugging of 
the blood-vessel, etc. 

I . Conditions Modifying the Cardiac Elements of the Pulse . 
(a) Frequency. — While the average pulse rate is 72 



PALP AT I OX. 261 

per minute, there are certain normal variation-. 
Dsually the pulse of females is slightly quicker — 80 pel 
minute — and it has been claimed that in tall people the 
pulse is -lower. At birth the pulse is 120 to 140, and 
gradually diminishes in frequency until at six years of 
age it is 100, and at puberty 80 or less. In old age the 
pulse becomes slower, but in extreme age its frequency 
is increased. There is also a diurnal variation in the 
pulse rate corresponding to the body temperature, it 
being more frequent in the afternoon and evening and 
after eating, slower during sleep and during the early 
morning hours. While a pulse of 60 may be normal 
for one adult and 100 for another, usually a pulse of 
over 90 per minute is morbid. 

Increase in Frequency. — The rate of the pulse may be 
increased by the following: (a) Muscular exertion. 
(bj Mental and emotional excitement; the degree of 
increase will vary with the individual, according to the 
irritability of the nervous system (temperament). 
(c) Eerlex irritation from other organs, especially the 
abdominal and pelvic viscera. (d) Diseases of the 
nervous system, especially those involving the nervous 
mechanism of the heart through the pneumogastric, 
sympathetic nerves or the cardiac ganglia, (e) Fever. 
As a rule, for each degree of temperature above the 
normal there is an increase of eight or ten beats. Cer- 
tain diseases do not conform to this rule : thus in typhoid 
fever the pulse is generally slow in proportion to the 
temperature, and is of diagnostic value in differentiat- 
ing this disease from tuberculosis and septic conditions. 
When, in typhoid fever, the pulse rate corresponds to 
the temperature range, it indicates a grave condition. 
In scarlet fever, with the verv beainnino; of the throat 
symptoms, the pulse ranges from 120 to 160, and this is 
of great aid in differentiating scarlatinal sore throat 
from that due to other causes, as diphtheria, simple 
follicular tonsillitis, etc. In fevers due to septic infec- 
tion the pulse is accelerated out of proportion to the 



262 



THE CIRCULATORY SYSTEM. 



Sphygmographic Tracings of the Pulse. 



Fig. 42. 



JWVA^ 



Right radial artery- Left radial artery- 

Aneurysm of arch of aorta. 



Fig. 43. 




Slow pulse (60) (acromeglia), 



Fig. 44. 



Small, thready, rapid pulse (98) (chill of malaria fever), 



Fig. 45. 



High-tension pulse (chronic nephritis). 



Fig. 46. 




Low-tension dicrotic pulse (pneumonia, eight hours before death), 



Fig. 47. 



Low-tension pulse, feeble cardiac action (typhoid fever, third week). 



PALPATIO^. 



26* 



)6 



range of temperature, and in the puerperium a rapid 
pulse, with slight elevation of temperature, is a sus- 
picious sign, (f) Anaemia and debility, (g) Inspira- 
tory diseases. In nearly all of the acute inflammatory 
diseases of the respiratory tract the pulse rate is in- 
creased. Normally the ratio between pulse and respira- 
tion is 4 : 1. This ratio is disturbed in respiratory 

Fig. 48. 




Rapid (100) low-tension, dicrotic, on admission. 



Fig. 49. 




Twelve hours later, free stimulation, slower (88), 



Fig. 50. 




Six hours after crisis (86). Four days later, no stimulation. 
Showing variation of pulse in pneumonia. 

diseases, such as pneumonia, when the ratio becomes 
3 : 1, or even 2 : 1 ; or equal. In febrile conditions 
due to pulmonary disease this sign is found of value 
when the usual physical signs are absent, (h) Cardiac 
conditions. The pulse may be accelerated in all valvular 
diseases, although as long as compensation is perfect the 
increase may be very slight. When there is muscular 



264 TBE CIRCULATORY SYSTEM. . 

insufficiency the rate is markedly increased, especially 
upon exertion. 

Acceleration of the pulse is a prominent symptom 
of neuroses of the heart. In Grave's disease the pulse 
ranges from 100 to 120 ; in paroxysmal tachycardia it 
may reach 160 or 200, but does not remain permanently 
at this point, although it may be constantly above the 
normal. In irritable heart (paroxysmal hurry) it is 
also increased. 

Rheumatoid arthritis, before marked deformity of 
the joints, frequently has a pulse, as an early symptom, 
of 110 or 120. 

The rate of the pulse bears a definite relation to the 
amount of tension in the blood-vessels, and should always 
be considered in this relation. 

Diminution in Frequency. — As mentioned before, the 
pulse may be habitually slow as an individual pecu- 
liarity. Usually a pulse under 60 is considered morbid, 
while a pulse of 40 is usually of grave significance. 

The pulse may be slowed by (a) reflex nervous irrita- 
tion, (b) Nervous diseases, especially those which 
cause increase in the intercranial pressure, as tumors, 
hemorrhage and meningeal effusion. It is also slowed 
in certain cases of mania, melancholia and general 
paralysis of the insane, and in injury to the cervical 
portion of the spinal cord. A slow pulse in epilepsy is 
always a grave symptom. In myxoedema the pulse is 
constantly slow, (c) Convalescence from fevers, (d) 
Toxaemias, especially bile, urea and certain acute dis- 
eases, (e) Increase in arterial tension, (f) Cardiac 
disease. A slow pulse is a grave symptom when it 
occurs in cardiac disease, and was formerly supposed to 
be pathognomonic of fatty degeneration of the heart, 
but is not usually present except when the degenerative 
change is due to atheroma of the coronary arteries. 

The pulse is not always a true guide to the frequency 
of the heart, as a form of slow pulse occurs in which 
only every other beat of the heart is felt at the wrist. 



PALPATIO*. 265 

The examination of the heart shows that the beat which 
is not felt as a pulse in the artery is feeble and incom- 
plete. This type of slow pulse is most frequently 
present in mitral stenosis. This form of infrequency 
often alternates with a form of irregularity called 
''pulsus trigeminus," as will be explained later. 

(b) Foece. — The force of the pulse wave is 
dependent on the energy with which the blood is forced 
by the ventricle into the aorta. It bears a certain rela- 
tion to the force of the apex beat, so far as it (the apex- 
beat) depends upon the muscular strength of the left 
ventricle. This rule holds good as long as the ventricle 
propels into the aorta the normal amount of blood in 
the normal time, as the fullness of the arterial system 
during the entire cardiac cycle is an important element 
in the strength of the pulse. 

Increase in Force. — The force of the pulse wave is 
increased (a) when the cardiac action is more vigorous 
than normal, as occurs in exercise, in mental and 
emotional excitement, and in cardiac neuroses, as 
Grave's disease, (b) When the cardiac muscular power 
is increased above the normal, due to change in the 
muscle, as occurs in simple hypertrophy of the left ven- 
tricle. When, in addition to hypertrophy of the muscle 
wall, the cavity of the left ventricle is enlarged (dilata- 
tion), not only is the force of the blood wave augmented, 
but it has greater volume. 

Diminution of Force. — The pulse wave may be de- 
creased in strength (a) when the contraction of the 
cardiac muscle is less forcible on account of general 
muscular weakness, as in debility, or due to lack of 
nerve tension, as in neurasthenia, etc. (b) When there 
is true muscular weakness, as occurs in cardiac degenera- 
tion, which may be primary or secondary to valvular 
disease of the heart, (c) When the amount of blood 
that is forced into the aorta is decreased through imper- 
fect emptying of the heart from cardiac weakness, from 
imperfect filling of the left ventricle, and general reduc- 
tion in the amount of blood, as in hemorrhage. 



266 TBE CIRCULATORY SYSTEM. 

Irregularity in Force. — In health the individual beats 
have the same volume. Under certain conditions there 
is inequality of force, some of the beats being fuller than 
others (Pulsus Alteram). This form of irregularity is 
present most frequently in mitral regurgitation, when 
dilatation and weakness of the left ventricle occur; it 
may be made more pronounced by raising the arms above 
the head, increasing the action of gravity. Its presence 
should always direct attention to the condition of the 
cardiac muscle. When irregularity in force is due to 
muscular insufficiency, slight exertion is often sufficient 
to induce also irregularity in rhythm. 

Physiologically there is a slight change in the force of 
the pulse with inspiration. This is not perceptible to the 
finger, and only to a slight degree in sphygmographic 
tracing. In certain pathological conditions the pulse 
may become distinctly slower and weaker during in- 
spiration (Pulsus Paradoxus.) Perceptive variation in 
the force of the pulse may be produced (1) by mechan- 
ical pressure upon the vessels within the chest by which 
the pulse is obstructed, as mediastino-pericarditis, tu- 
mors, aneurisms, etc. When due to this cause there is 
marked discrepancy between the forcible apex beat and 
the increased cardiac sounds and the weak pulse. (2) 
Conditions which cause increase of negative pressure 
through the obstruction of the entrance of air into the 
lung, as laryngeal and tracheal stenosis, asthma, obstruc- 
tive bronchitis, pneumonia and occasionally in pleurisy 
with effusion. When pulsus paradoxus is caused by 
obstruction, especially laryngeal and tracheal, with each 
forcible inspiration the pulse may disappear from the 
wrist. (3) Cardiac weakness becomes so extreme that it 
cannot overcome the normal negative pressure of the 
intrathoracic pull exercises by the action of the respira- 
tory muscles. 

( c) Ehythm. — The normal rhythm of the heart may 
be disturbed in two ways: (a) A beat is dropped at 
more or less regular intervals, giving the intermittent 



PALPATION. 267 

type of pulse, (b) The beat occurs at irregular inter- 
vals, giving the true irregular or arrhythmical pulse. 

Intermittent Pulse. — Intermittent pulse has the char- 
acteristic that, with the exception of the missing beat, 
the pulse is regular. The intermission may occur 
according to rule; that is, after a definite number of 
beats, as when the fifth, seventh, eleventh or twenty-first 
beat is lost ; or it may follow no rule. Examination of 
the heart may show a corresponding omission of the 
cardiac systole (pulsus deficiens), or that there is^ a 
cardiac systole, but too weaak to be felt at the radial 
artery (pulse intermittens). 

When the intermittent pulse is habitual the inter- 
mission is apt to be according to rule. This form is of 
little clinical significance, being often a constitutional 
peculiarity ; or it may be caused by the use of tea, coffee, 
tobacco, etc. It must be borne in mind that the inter- 
mission usually disappears during pyrexia from any 
cause, and returns with the normal temperature. When 
it returns during the height of the temperature it is an 
unfavorable sign. 

In degeneration of the myocardium and in valvular 
diseases the pulse may be intermittent while the patient 
is at rest, but on exertion the intermission is replaced by 
true irregularity, with shortness of breath and other 
signs of cardiac insufficiency. When the intermission 
is due to some disturbance of innervation, on exertion 
such change does not occur, or the rhythm may become 
perfectly regular. Broadbent claims that an intermit- 
tent pulse is not a contraindication to the administration 
of anesthetics (chloroform), but that the condition of 
the pulse should be watched during the early stage of 
narcosis. Generally the intermission disappears, but if 
from the first the pulse becomes weak and irregular, the 
administration of the anaesthetic should cease. The 
same rule applies to ether and nitrous oxide. 

Irregular Pulse. — Irregular pulse has the character- 
istic that the beats follow each other at irregular in- 



268 



THE CIRCULATORY SYSTEM. 



tervals, and are also irregular in force. The tendency 
to irregularity varies at different periods of life. Dur- 
ing infancy the pulse is easily disturbed in all its cardiac 
elements, especially its rhythm. The same tendency to 



Fig. 51. 




Pulse 



irregular in rhythm and force (myocarditis with dilatation). 



Fig. 52. 




Mitral regurgitation. 



Fig. 53. 



Aortic obstruction. 



Fig. 54. 




Aortic regurgitation. 



Fig. 55. 




Mitral stenosis. 



arrhythmia is noted in extreme old age. Irregularity of 
the pulse may be a normal condition in individuals when 
it is constant. 

The causes of irregularity may be : (a) Reflex irri- 



PALPATIOX. 269 

tatiori from abdominal or pelvic viscera, especially when 
they are associated with flatulency and displacement 
upward of the diaphragm. (^Disturbances of the 
nervous system by shock, grief, continued worry 
neurasthenia, anaemia, debility, etc. (c) Diseases of 
the brain and meninges, (d) Toxaemia, due to alcohol, 
tea, coffee, tobacco, digitalis, belladonna, etc., or that of 
the infectious diseases, especially the early stage. The 
irregularity that occurs later in acute disease may be 
due to the toxaemia or to degenerative changes in the 
cardiac muscle. (e) Cardiac diseases. In valvular 
disease marked irregularity does not occur during stage 
of compensation, but is one of the early signs of muscu- 
lar insufficiency. In mitral stenosis it is a common, but 
not grave, symptom. In all forms of myocarditis it is 
an important prognostic sign. 

II. Conditions Modifying the Elasticity of the Arteries. 
—The sensation conveyed to the finger by the normal 
artery has been described, and attention called to the 
necessity of discriminating between the degree of com- 
pressibility due to changes in the coat of the artery and 
that due to increased blood pressure. When the coats of 
the arteries are thickened and rendered inelastic by 
increase of fibrous tissue, the pulse wave will be obliter- 
ated with difficulty, and beyond the point of compression 
distallv the artery will be easily detected as a more or 
less rigid cord. As the tube becomes more inelastic it 
becomes longer and tortuous, and each pulse wave is felt, 
not as a beat, but as a worm-like movement. Calcare- 
ous deposits may be detected as isolated plates, and 
"may feel like a string of beads under the finger." 

III. Conditions Modifying Resistance in Arteries and 
Capillaries.— The amount of arterial and capillary resist- 
ance determines the size, intensity and duration of the 
normal pulse, and any change in the degree of resistance 
influences all of these elements. 

Diminution of Resistance. — When the resistance 
is reduced below normal, there is a relatively greater 



270 TEE CIRCULATORY SYSTEM. 

increase in the distension of the artery with each ven- 
tricular systole. The pulse wave passes more rapidly 
under the finger, and between the beats the artery is but 
slightly distended * with blood, and is almost obliterated 
by light pressLire of the examining finger ; and the pulse 
felt at the wrist has the following characteristics : The 
pulse wave dilates suddenly the flattened artery, giving 
the sensation of a large-sized pulse ; it does not gradually 
reach its acme, but seems to reach the finger full size. 
The beat is sharp, passes quickly under the finger (short 
duration) and the artery remains distended but for a 
very short time (tension rapidly fallsj. This type of 
pulse is spoken of as "large, short, low-tension pulse." 

In the normal pulse the examining finger can scarcely 
detect dicrotism, which is caused by the elastic recoil of 
the artery on the closure of the aortic valves, although it 
is very perceptible in the sphygmograph tracing. (Fig. 
41.) When the resistance in the arteries is very low this 
wave becomes quite apparent to the finger, and the pulse 
is spoken of as dicrotic. 

In low tension the force and frequency of the heart 
determines the type of pulse. When the heart is beat- 
ing rapidly and forcibly the arteries are kept well 
filled, the pulse wave is felt as a large, sharp, well- 
sustained beat, and the pulse is called "full and 
bounding," and is easily obliterated. Dicrotism, while 
present, is not noticed, on account of the size of 
the primary pulse wave. As the force of the heart 
diminishes the pulse becomes less full, and is sharper 
and shorter and more easily obliterated by light 
pressure on the artery, and the dicrotic wave becomes 
more pronounced. This type of pulse is spoken of as 
the "gaseous pulse." When the heart power becomes 
insufficient to empty the left ventricle the pulse is weak 
and characterless — "small, running pulse" (page 262). 

Causes of Low Tension. — (a) Low tension may be 
a constitutional peculiarity in some individuals and 
families, when it may be associated with increased fre- 



PALPATION. 271 

quency in some cases or obesity and weak cardiac 
action in others (diminution in capillary resistance). 
(b) Temporary low tension is caused by warmth, as 
weather, baths, hot drink and food, (c) It may be 
dependent upon nervous cause?, as mental or nervous 
exhaustion from whatever cause, (d) Debility due to 
malnutrition or secondary to chronic disease. (e) 
Pyrexia generally causes a full, bounding pulse, usually 
in proportion to its degree. Later the pulse may become 
weak, quick and dicrotic, on account of the effect of the 
high temperature on the cardiac muscle or the influence 
of the toxines on the heart itself, or on the nervous sys- 
tem, (f) Cardiac diseases. As the pressure in the 
arterial system depends upon the amount of blood that 
is forced into it, as well as the resistance to the passage 
of the blood through the arterioles and capillaries, the 
tension will be lowered whenever the heart is unable to 
empty itself on account of valvular disease or of muscu- 
lar weakness. In aortic insufficiency the collapsing or 
water-hammer pulse is due to the sudden fall in the 
blocl pressure caused by the free regurgitation of blood 
into the ventricle. The peculiarities of this pulse will 
be described under Aortic Regurgitation. 

Increase of Resistance. — In normal conditions there 
is a certain correlation between the force and frequency 
of the heart and the outflow from the arterioles, and a 
normal mean blood pressure is maintained. The normal 
blood pressure varies at different periods of the cardiac 
cycle. With cardiac systole, the pressure is raised to 
the maximum, and the artery is felt as a tense, distended 
tube. During diastole, as the pressure gradually sub- 
sides, the tube becomes lax. and can no longer be felt. 
When resistance to the outflow of blood is increased the 
tension is increased, the pressure in the blood-vessels 
does not subside, and the artery remains filled, so that it 
is detected not only with the beat, but in the interval. 
The sensation conveyed to the finger by the pulse wave 
also is changed. The examining finger not causing so 



272 THE CIRCULATORY SYSTEM. 

marked a flattening of the artery, there is less motion 
felt, and the pulse wave slowly reaches its height to 
slowly decline. As the size of the artery is not much 
altered between the pulse waves by light pressure the 
pulse is small, and the wave gradually distends the ves- 
sel and is felt for a relatively long period, and the artery 
remaining perceptible in the interval. 

As in low tension, so in increased resistance, the type 
of the pulse will vary with the force and frequency of 
the heart and the condition of the large blood-vessels. 
When the muscular power of the heart is sufficient to 
overcome the resistance in the blood-vessels, and the 
muscular coats of the aorta oppose the increased cardiac 
action, the tension in the arteries will be sustained 
almost uniformly during the interval, and the pulse will 
be correspondingly small, long and of high tension. 

When the heart fails the pulse becomes irregular and 
arterial pressure is lowered. When, on the other hand, 
the aorta and large vessels yield to the blood pressure 
and become dilated, the pulse becomes larger and the 
duration is shorter, although the arteries remain over- 
filled during diastole. 

Causes of High Tension. — (a) Temporary high-ten- 
sion pulse may be caused by increase in the amount of 
blood, as occurs for a short time after meals or after tak- 
ing large quantities of water, and is persistent when the 
elimination of the fluid by the skin and kidneys is inter- 
fered with, producing permanent overdistension of the 
blood-vessels, (b) It may be also temporarily increased 
by frequent and powerful overaction of the heart, as 
occurs in mental or emotional excitement and in the 
early stage of physical exertion. Or ( c) it may be due 
to temporary increased resistance in the blood-vessels, as 
occurs from external cold, congestive chill, or hysteria. 
(d) Drugs, ergot and the digitalis group. Permanent 
high tension may be caused by all those factors which 
cause increased resistance in the capillaries, as (a) 
chronic toxemia, as occurs in gout, rheumatism, lead 



PALPATION. 273 

poisoning and in renal disease ; (b) changes in the walls 
of the capillaries which interfere with permeability, as 
atheroma and arterio-capillary fibrosis. These changes 
may be primary or secondary. 



18 



CHAPTEK X. 

PERCUSSION. 

By percussion of the cardiac region it is possible 
(a) to determine the size of the heart in certain dimen- 
sions only; (b) its relation to other thoracic and ab- 
dominal organs ; (c) changes in the outline of certain 

portions. ( . 

Percussion of the prsecordium gives two areas: (lj 
The area in which the clear pulmonary resonance be- 
comes more and more impaired by the presence of the 
airless structure of the heart ; that is, the area of relative 
cardiac dullness. (2) The area in which no pulmonary 
resonance can be detected, the area of absolute cardiac 
dullness or cardiac flatness. The percussion outline ol 
these two areas is most difficult to determine. Many 
claim that they have no value, or, at least, only a limited 
value in the diagnosis of cardiac diseases. 

The amount of information obtained by percussion 
over the -prsecordium depends upon the technique and the 
acuteness of the examiner, and whether or not the ex- 
amination is conducted methodically and for a definite 

purpose. . 

Methods of Examination.— In percussing lor relative 
dullness it is most important that the line should be 
determined at which the normal pulmonary resonance 
is impaired bv the underlying heart. 

Percussion is begun over the thorax at some distance 
from the anatomical borders of the heart. The finger is 
placed across the ribs parallel with the sternum, and 
forcible percussion is made, the finger being moved in- 
ward toward the cardiac area till slight change m the 
percussion note is detected. This point is marked on the 



PERCUSSION. 275 

thorax, and the same area is again percussed with blows 
varying in strength, with the finger both in the vertical 
position and also parallel to the ribs lying in the inter- 
spaces, until the positive point of cardiac dullness is de- 
termined. This method is carried on at different levels 
until the outermost area of cardiac dullness is outlined. 

After this has been determined the examiner then pro- 
ceeds to outline the point at which the pulmonary reso- 
nance ceases and the heart, in contact with the chest 
wall, causes a perfectly flat note. It is necessary that 
the percussion blows vary in force as we proceed from 
the outer line of cardiac dullness, where the layer of 
lung is relatively thick, toward that of cardiac flatness. 

The Area of Cardiac Dullness. — In the normal adult the 
outer area at which cardiac dullness is detected is as 
follows : On the right side no change is noted above the 
third rib, except occasionally a slight loss of resonance 
due to the underlying aorta. Although the right auricle 
projects beyond the sternum opposite the third costal 
articulation it is impossible to accurately map out the 
border which extends beyond the sternum, as the thick- 
ness of the pulmonary tissue is so great that percussion, 
sufficiently strong to penetrate to the underlying heart, 
will set up lateral vibrations also, which, being conveyed 
to the sternum, give a resonant note. The most that 
can be detected on the right side by skillful percussion 
and a trained ear is a slight change in resonance, extend- 
ing from the fourth rib to the area of liver dullness. 

On the left side, that portion of the heart that lies 
above the third rib cannot be detected by percussion, on 
account of the thickness of the pulmonary tissue and its 
close proximity to the sternum. At the lower level of 
the third rib, close to the sternum, the deep cardiac dull- 
ness is detected. The line of dullness extends in a 
curved line across the third intercostal space to the 
middle of the fourth rib, 3% to 4 inches from the mid- 
sternum and just inside the nipple line. From this 
point it runs almost vertically downward to the sixth 



276 THE CIRCULATORY SYSTEM. 

rib, just inside the nipple line. When the heart and 
structures contained within the mediastinum are normal 
they do not influence to any appreciable degree the re- 
sonance of the sternum. (Fig. 30.) 

The Area of Cardiac Flatness. — That portion of the 
heart that lies in direct contact with the chest walls gives 
a perfectly flat sound on percussion, and corresponds in 
outline to the anterior margin of the left lung. The 
resonance of the sternum prevents that portion of _ the 
heart that lies between the anterior edge of the right 
lung and the left edge of the sternum being detected by 
percussion. The thin lingula pulmonalis that covers 
the apex of the lung does not modify the flat percussion 

note. (Fig. 31.) 

The normal area of cardiac flatness is somewhat 
quadrangular in shape. The right border extends along 
the left edge of the sternum, from the upper edge ol 
the fourth rib and along the border of the sixth rib, 
where it merges into the hepatic flatness. 

The upper borders run diagonally across the fourth 
rib for about two inches, and then vertically downward 
to the sixth rib. Accurate mapping out of the borders 
of cardiac dullness and flatness being very difficult, some 
authors have recommended that the area of cardiac flat- 
ness be estimated in two directions only : 

(1) The vertical line. Percussion is made along the 
para-sternal line, one inch to the left of the sternum, 
and the following variations in resonance are noted on 
percussion over the normal heart: (a) From the 
clavicle to the upper border of the third rib full pul- 
monary resonance is detected, (b) From the third rib 
there is a gradual diminution of resonance and a height- 
ening of pitch (cardiac dullness), until at the upper 
border of the fourth rib there is absolute loss of reso- 
nance (cardiac flatness), (c) From the upper border 
of the fourth rib the sound is flat, and merges, below the 
sixth rib, into that of the liver. Over this normal flat 
area very forcible percussion may detect a deep-seated, 



PERCUSSION. 277 

tympanitic resonance when distension of the stomach or 
intestines is present. 

(2) Transverse line. Percussion is made along a 
line which corresponds to the upper edge of the fourth 
rib on the left side. The sound is flat for 2 to 2 1 / / o 
inches from the edge of the sternum, when it merges 
gradually into dullness, which terminates just inside the 
nipple line. 

Numerous modifications of the ordinary method of 
percussion by the finger have been devised in order to 
increase the ability to outline the heart. The most im- 
portant are: (a) Auscultatory percussion (page 
102), (b) Plessimetric percussion or Sanson's method. 
Instead of the finger, a pleximeter of vulcanite is used. 
This pleximeter consists of two thin, flat, oblong plates, 
one 1 x y 2 inch, the other % x % mc ^ ? joined in the 
middle by a central square column 1% inches high. It 
is closely held to the chest wall by the index and middle 
fingers of the left hand, placed on either side of the 
vertical column. "The observer commences by apply- 
ing the pleximeter with its long diameter parallel to the 
sternum, about midway between the axilla and the right* 
sternal border, percussion being made upon the summit 
of the column by one or two fingers of the right hand, 
the strokes from the Avrist being sharp and decisive, 
though not necessarily forcible. This procedure in the 
normal conditions elicits the normal thoracic vibrations. 
The pleximeter is then approached nearer and nearer — 
always in parallel lines — to the sternum, until the line 
is reached where the vibrations are sensibly modified. 
By slightly inclining the pleximeter so that the vibra- 
tions come from its left edge there is practically a line 
of surface without noticeable breadth. The point at 
which the resonance is modified is marked. By repeat- 
ing the process just described at higher and lower levels, 
and uniting the marks, the observer delineates the area 
on the right side of the outer border of the heart dull- 
ness. In like manner, by percussing from above down- 



278 THE CIRCULATORY SYSTEM. 

ward, with the long diameter horizontal instead of ver- 
tical, the upper limit of the liver, as indicated by an area 
of modified vibrations, is arrived at." 

In percussing on the left side of the chest, the observer 
begins at the left of the second rib, 2 or 3 inches to the 
left of the sternal border, and approaches to the right 
until the line of modified vibration is arrived at, which 
will be nearly parallel with that obtained on the right 
side. 

Percussion is made at different levels, as on the right 
side, until the heart is outlined. 

By this method not only is the outer border of the 
heart noted by the ear, but also detected by difference 
in vibrations, as felt by the finger resting on the lower 
plate. A certain amount of experience is needed in 
order to obtain the best results by this method. 

(c) Palpatory Percussion. — By this method both 
palpation and percussion are employed at the same time. 
The palmar surface of the terminal phalanx of the 
middle and first fingers are placed upon the chest and a 
light tap is made with these alternately. The finger is 
allowed to remain for an instant in contact with the part 
percussed, so as to note the amount of resistance. The 
disadvantage of this method is that a certain amount of 
pain is given. Ebstein modified the method by using a 
pleximeter of glass 1% inches wide, 1% inches in length 
and with a circular stem % inch. This is applied to the 
chest in a manner similar to that used by Sanson with 
his pleximeter, except that the blow is a firm pressing 
stroke rather than the sharp, quick blow of ordinary 
percussion. 

(d) Friction Auscultation. — In this method, by rub- 
bing on the surface of the skin with a hair pencil 
(Smith), or by a rod (Reichmann), vibrations are set 
up which are transmitted in various directions and are 
said to be interfered with in a characteristic manner by 
the different thoracic organs. The advocates of this 
method have claimed great precision for it. Indepen- 
dent observers have not been able to verify these claims. 



PERCUSSION. 279 

Conditions Modifying the Normal Areas of Cardiac Flat- 
ness and Dullness. — Both areas may be proportionately 
increased or diminished, or the dimensions of one may 
be altered at the expense of the other. 

Normal Variations. — The size and location of the 
percussion areas are influenced (a) by the age of the 
individual; (I) by the posture of the patient; (c) hj 
the condition of the lungs according to forcible inspira- 
tion and expiration; (d) by the position of the heart 
due to elevation or depression of the diaphragm. 

In children the heart is relatively larger than in 
adults, and lies higher in the thorax, while the greater 
elasticity of the lungs and flexibility of the bony thorax 
causes a much larger portion of the heart to be un- 
covered by lung tissue and in closer contact with the 
chest wall. In children, during full inspiration, the 
area of cardiac dullness is relatively increased, while 
that of flatness is diminished ; and the reverse condition 
obtains during shallow breathing and full expiration. 
The elasticity of the sternum and costal cartilages per- 
mits dullness to be detected at the right border of the 
sternum. The upper border of cardiac dullness reaches 
the middle of the second intercostal space in the para- 
sternal line, and the outer left border to the nipple line 
at the third interspace. At the lower border of the 
fourth rib it extends a quarter to a half inch beyond the 
nipple line. The shape of the area of cardiac dullness 
is somewhat semicircular, with the convexity upward. 
The area of absolute flatness in children is also increased 
in extent and raised by the width of an interspace. The 
right border is close to the left sternal margin; the 
upper line is in the third interspace, and extends almost 
straight across to the upper border of the third rib, close 
to the mammary line. The left border is usually just 
within this line, and extends to the lower edge of the 
fifth rib. 

It is necessary to bear in mind the variations in the 
cardiac percussion area that occur in children, as they 



280 THE CIRCULATORY SYSTEM. 

have an important bearing on the diagnosis of effusions 
into the pericardium. 

In old age the areas are smaller and lower in position. 
In the left para-sternal line the upper limit of dullness 
is about the lower border of the fourth rib, and of flat- 
ness about the middle of the fifth rib. The left border 
is also nearer the median line. 

The position of the patient alters in a slight degree 
the percussion areas. They are the same whether the 
patient is lying on the back or in the upright position. 
When lying on the right side, the area of flatness to the 
left of the sternum diminishes or disappears entirely. 
A smaller area of flatness may be detected just to the 
right edge of the sternum, in the third interspace. When 
lying on the left side the area of flatness is increased, the 
left border being carried nearly to the mammary line. 

Influence of the Soft Parts. — The effect of the soft parts 
on the resonance of the thorax has already been^ con- 
sidered. When the thorax is thickly covered it is 
impossible to accurately outline the area of cardiac flat- 
ness, that obtained by light percussion being generally 
carried too far to the left. 

Influence of the Bony Thorax. — The elasticity of the 
bony thorax also exerts an influence on the percussion 
areas. As before explained, the highly elastic thorax 
of the child will give a much more accurate outline of 
the heart than the rigid and more resonant thorax of the 

adult. 

Influence of the Lung and Pleura. — As the area of 
cardiac flatness corresponds to that portion of the heart 
that is uncovered by lung tissues and the area of rela- 
tive dullness to the part covered by a thin layer, both 
areas will be increased or diminished by changes occur- 
ring in the lung or pleura. The normal variations in 
size occur, as has already been mentioned, during the 
ordinary acts of respiration. Enlargement of the lung, 
as occurs in general emphysema, causes a smaller part 
of the heart "to be in contact with the chest wall, in- 



PERCUSSION. 281 

creases the thickness of the layer of lung covering the 
heart, and displaces the heart downward and toward the 
median line. These changes cause the area of cardiac 
flatness to be diminished or absent. As emphysema is 
usually attended with hypertrophy and dilatation of the 
right side of the heart, the areas of percussion dullness 
and flatness do not correspond to the size of the heart, so 
that a normal area of cardiac flatness, occurring with 
other physical signs of emphysema, is always indicative 
of a marked right-sided cardiac hypertrophy and dilata- 
tion. In compensatory emphysema of the left lung, both 
cardiac dullness and flatness to the left of the sternum 
may be diminished or absent. When the heart is dis- 
placed to the right an area of varying dullness may be 
detected to the right of the sternum. In compensatory 
emphysema of the right side pulmonary resonance ex- 
tends to the left of the sternum, and the right border of 
cardiac flatness is moved further from the left sternal 
margin. 

The area of cardiac flatness may be enlarged in all 
directions by retraction or consolidation of the anterior 
border of the lung, or thickening of the pleura. Eetrac- 
tion of the anterior border of the left lung, by uncover- 
ing the heart, increases the area of flatness at the expense 
of 'that of dullness, the shape of the area of flatness cor- 
responding to changes in the lung and secondary dis- 
placement of the heart. 

When the anterior border of the right lung is re- 
tracted, cardiac dullness may be detected to the right of 
the sternum. When the heart is displaced to the right 
the degree of dullness will depend upon the extent to 
which the heart is in close contact with the chest wall. 

Increase in the area of flatness over the praecordia may 
be due to changes in the pleura or to consolidation of 
that portion of the lung overlying and surrounding the 
heart. It is impossible by percussion alone to determine 
where cardiac flatness ceases and that due to pulmonary 
or pleural change begins. Effusion into either pleural 



282 THE CIRCULATORY SYSTEM. 

investment may cause some enlargement of the cardiac 
area of flatness. 

Influence of Changes in the Pericardium. — Changes in the 
pericardium increase the area of flatness either by 
causing hypertrophy of the heart (adhesive pericarditis), 
or distension of the sac (effusion). Fluid in the peri- 
cardium, collecting in the most dependent portion of the 
sac, causes (a) increase in the transverse diameter of 
flatness and marked dullness to the right of the sternum, 
beginning in the fifth interspace on the right side. On 
the left side the flatness extends upward and toward the 
nipple line. As the fluid increases in amount the shape 
of the area of flatness over the prsecordia becomes more 
triangular, with a broad base below and blunt apex 
above. The amount of fluid determines the size and 
shape of the triangle, and causes the area of deep-seated 
dullness to be replaced by flatness, surrounded by a zone 
of tympanitic pulmonary resonance. The resonance 
over the sternum is also changed when the fluid in the 
pericardium exerts pressure on it. Pneumopericardium 
causes the cardiac flatness to be replaced by a low- 
pitched tympanitic resonance. 

Influence of Cardiac Changes. — Increase in the size of 
the heart, whether due to hypertrophy or dilatation, or 
both, increases the area of cardiac dullness to a much 
greater degree than that of absolute flatness, which, as 
before shown, is generally increased by causes external 
to the heart. 

The size and shape of the increase in cardiac dullness, 
or flatness due to cardiac hypertrophy and dilatation, 
varying according as the right or left side is affected. 
Hypertrophy of the left ventricle causes the left border 
of both dullness .and flatness to be moved to the left and 
slightly downward. The upper border remains fairly 
constant, while the right border is unchanged. The 
area of dullness over the apex is pointed. When dilata- 
tion and hypertrophy are associated, the area of flatness 
is more quadrangular; the transverse diameter at the 



PERCUSSION. 



283 



level of the fourth rib is increased by extension toward 
the left, and the outline over the apex is rounded. In 
extreme dilatation and hypertrophy of the left heart, 
as occurs in insufficiency of the aortic valves, the left 
border of flatness may reach the anterior axillary line, 
and dullness the mid-axillary line. 

In hypertrophy or dilatation of the right side, when 
the ventricle alone is involved, the upper border of nat- 

Fig. 56. 




Percussion outline of cardiac dullness in cardiac dilatation with 

hypertrophy. 



ness at the level of the fourth rib shows no marked in- 
crease. The lower left border is carried slightly out- 
ward, and the right border remains at the left margin of 
the sternum. 

When dilatation and hypertrophy affect both ventri- 
cles and auricles the dullness may be detected beyond the 
right border of the sternum as high as the fourth costal 
cartilage. (Fig. 56.) Dilatation and hypertrophy of 
the right heart may cause slight change in the sternal 



284 TEE CIRCULATORY SYSTEM. 

resonance, but not to the same degree as pericardial effu- 
sion, aneurism, or mediastinal tumors. 

Percussion of the Aorta. — The great vessels normally 
give very slight and hardly perceptible dullness in the 
second interspaces. When any dullness is detected it is 
most marked on the right side and is rounded in outline. 
Increase of this area of dullness is generally due to 
aneurismal dilatation of the aorta, although mediastinal 
new growths can cause it. 



CHAPTER XL 



AUSCULTATION. 



Auscultation of the heart furnishes information 
concerning the normal cardiac sounds, (a) their relative 
rhythm, (b) character or quality, (c) points at which 
they are most distinctly heard (maximum intensity), 
(d) areas over which they are audible (areas of dif- 
fusion), (e) variations and modifications, both normal 
and abnormal; (f) abnormal or adventitious sounds 
(murmurs, frictions), etc., and (g) the degree to which 
they replace the normal cardiac sounds. 

Auscultation should always follow inspection, palpa- 
tion and percussion, as the data obtained by these 
methods are differentiated and enlarged by those de- 
tected by auscultation, while at the same time they cor- 
rect and define variations in the normal sounds and the 
significance of adventitious sounds. 

Methods of Examination — Both the mediate and the 
immediate methods of auscultation are employed, each 
having its proper field. 

By mediate auscultation, with the ear applied directly 
to the chest, the observer hears not only the sounds of 
the heart, but he also notes the impulse and other tactile 
sensations, and is thus able to gauge more accurately 
the period of the cardiac cycle at which both normal and 
abnormal sounds occur. 

Immediate auscultation, employing a stethoscope, in 
addition to the advantages noted under Auscultation of 
the Lung, is especially valuable in the examination of 
the heart, as it (a) limits the sonnd heard to that 
portion of the chest wall covered by the thoracic end of 
the stethoscope. This is very important, as the cardiac 
orifices are situated close to each other, and it is neces- 



286 THE CIRCULATORY SYSTEM. 

sary to determine where both normal and adventitious 
sounds are heard with the greatest intensity ; while with 
the ear alone we are apt to include more than one valve 
area in the scope of the examination, (b) It cuts off 
external sounds, (c) It intensifies some of the sounds 
produced in the heart, especially those due to valve 
action and murmurs. 

In selecting a stethoscope the following points should 
be observed : 

The binaural forms are mostly used. The advan- 
tages of the semi-rigid ones over those made with flexible 
tubes are increased power of conduction and conveyance 
of cardiac impulse, as well as sound. The disadvantages 
are a certain resonating effect, which increases the in- 
tensity and may change the character of the higher- 
pitched valve sounds and murmurs. In order that the 
stethoscope be a good conductor of sound, whether rigid 
or made of flexible (rubber) parts, the interior should 
be absolutely smooth. The thoracic end of the stetho- 
scope should be small, so as to fit closely to the surface 
of the chest and also limit the field of examination to a 
small area. The ear pieces should fit the ear without 
producing pain or discomfort. Usually too small ear- 
pieces are selected, which penetrate too deeply into the 
canal. The ear pieces should merely close up the wider 
portion of the orifice. The spring holding the ear pieces 
in place should not be too stiff, and where the instru- 
ment has to be used for long periods of time each day a 
form of stethoscope should be used in which the pressure 
of the spring can be regulated. 

The examination should be made methodically, and 
those portions of the heart should be first examined 
where the cardiac sounds are most distinct, both as to 
intensity and their relation to the ventricular systole. 

Normal Cardiac Sounds. — Two sounds are produced by 
cardiac action, each having a definite relation to the 
phase of cardiac cycle and differing in time, character, 
position of maximum intensity and area of diffusion. 



AUSCULTATION. 



287 



First Sound. — The first sound of the heart corre- 
sponds to the ventricular systole, closure of the mitral 
and tricuspid valves and opening of the aortic and pul- 
monary valves, with forcing of the blood stream from 
the right and left ventricular cavities into the pul- 
monary artery and aorta. The first sound of the heart 

Fig. 57. 




Area of crunching first sound. 



is a prolonged, low-pitched, dull sound, which has some 
resemblance to the sound made in the pronunciation of 
the syllable "lubb." 

The cause of the first sound of the heart is still a 
matter of dispute. Numerous theories have been ad- 



288 THE CIRCULATORY SYSTEM. 

vanced, but no one of them has been universally adopted. 
The consensus of opinion is that the first sound of the 
heart is composed of two elements : (a) The muscular 
element, due to the contraction of the cardiac muscle 
and its impact on the chest wall, giving the prolonged, 
dull, low-pitched quality, (b) The valve element, due 
to the closure of the mitral and tricuspid valves and 
stretching of the chorda? tendinese and papillary muscle, 
causes the short, sharp and high-pitched quality. As 
will be explained under Modifications of .Normal 
Sounds, the first sound will vary according as one or the 
other of these elements predominates. _ # 

The first sound of the heart is heard most distinctly 
at the region of the apex. At this point both muscular 
and valve elements are present. The muscular element 
predominates, because at the time it is heard the rigidly 
contracting apex of the heart strikes the chest wall and 
is momentarily held in contact with it, conveying the 
vibrations to the thorax. Frequently, as the stethoscope 
is moved from the base towards the apex of the heart, the 
muscular element of the first sound becomes intensified, 
the "lubb" character of the sound is changed, and below 
the lower border of the fifth rib or the upper border of 
the sixth and extending from the edge of the sternum to 
the apex the sound has a somewhat creaking leather, or 
crunching sound which may be mistaken for a friction or 
a murmur. (Fig. 57.) 

Second Sound.— The second sound of the heart corre- 
sponds to the closure of the aortic and pulmonary valves. 
It is shorter, sharper and higher pitched than the first 
sound of the heart, being somewhat similar to the sound 
produced by the pronunciation of the syllable "dubb 
It is composed of one element only, the valve sound, 
which is short, tense and snapping, and may be very 
closely imitated by stretching with more or less sudden- 
ness a piece of cloth or a moistened membrane. 

(Sanson.) . 

The second sound of the heart, being composed en- 



AUSCULTATION. 



289 



tirely of the sounds made by the closure of the aortic 
and pulmonary valves, is heard most distinctly over the 
base of the heart. 



Fig. 58. 




Diagrammatic representation of the movements and sounds of the 
heart. (After Shaepey). This diagram shows merely the general 
relations of the several events, and does not represent exact measure- 
ments. 

In a heart beating seventy-two times a minute, Foster estimates 
each entire cardiac cycle as occupying about 0.8 sec, of which 0.3 
sec. represents the duration of the systole of the ventricle, 0.4 sec. 
the diastole of both auricle and ventricle, or the "passive interval," 
and 0.1 sec. the systole of the auricle. 

Only one "pause" is marked here — somtimes called the "long 
pause ;" some writers describe a "short pause" also — indicated in 
the diagram by the small space between the first and the second sound. 



GRAPHIC METHOD OF RECORDING CARDIAC SOUNDS. 

The normal first and second sounds may be graphic- 
ally indicated by symbols : 

— = First sound. 

(J = Second sound. 

— U = Normal cardiac sounds. 

19 



290 THE CIRCULATORY SYSTEM. 

\.\J ^Prolonged first sound. 

iy = Accentuated first sound. 

iy = Shortened first sound, 

i = Feeble or diminished first sound. 

O = Absence of first sound. 

\j = Valvular element of first sound predominates. 

y := Reduplication of first sound. 

,+. = Accentuation of second sound. 



+ 



= Accentuation of second sound at aortic or pulmonic 



\JWer<P) valves 

_^j = Feeble second sound 

= Murmur. 




Time of the murmur can be indicated by — U or by 
first sound or second sound. 

Area of diffusion by projection of shading or arrows. 

Valve Areas.— Listening over certain portions of the 
chest, the first and second sounds are heard with vary- 
ing intensity and clearness, and it is possible to appre- 
ciate the sounds made at the different valves. The 
areas at which the valve sounds are best heard are called 
valve areas, and are named according to the valve 
whence the sound proceeds— aortic area, pulmonary 
area, tricuspid area and mitral area. The areas do not 
correspond to the anatomical situation of the valves 
(Fig. 11), but to points on the surface of the chest, to 
which the vibrations made at the valves are conducted 
with the greatest intensity. (Fig. 59.) 

The Mitral Area. — The valvular element of the first 
sound, heard at the fifth intercostal space, is that pro- 
duced by the mitral valve. The location of the mitral 
area does not correspond with the anatomical site of 
this valve, which is situated behind the left half of the 



AUSCULTATION. 



291 



sternum, opposite the insertion of the fourth left costal 
articulation. The conduction of the vibrations made at 
the mitral valve to the apex is through the tense chorda? 
tendinea? and papillary muscle and the ventricle wall. 

The Tricuspid Area.— The sound made at the tri- 
cuspid valve is heard over the lower end of the sternum. 
Conduction of the sound from seat of production to the 

Fig. 59. 




From above downwards, showing the anatomical positions of the 
pulmonic, aortic, mitral and tricuspid valves. The arrow-heads show 
their respective sites of audibility. Shaded portion shows part of left 
heart projecting beyond the right heart. 

lower end of the sternum is due to conveyance by the 
chorda? tendinese and papillary muscle on the right side 
to that portion of the right ventricular Avail which is in 
close contact with the lower left edge of the sternum. 
The Aortic Area is in the second right intercostal 



292 TEE CIRCULATORY SYSTEM. 

space, close to the sternum, and the second right carti- 
lage has been called the "aortic cartilage." The aortic 
valve is situated lower than this area, being behind the 
left half of the sternum to the left of th e> right third 
interspace. The vibrations made at the aortic orifice are 
conveyed to the aortic area through the tense walls of the 
aorta, which at this point come closely in contact with 
the chest wall. 

The Pulmonic Area is at the second left intercostal 
space, close to the sternum, and corresponds more nearly 
than do the other areas to the anatomical site of the 
valve, which is slightly lower under the third intercostal 
cartilage, extending slightly into the second interspace, 
Modifications of the Cardiac Sounds. — The cardiac 
sounds may be modified (a) in intensity, which may be 
increased or diminished, and (b) in rhythm, which con- 
cerns the duration of the pause which separates the 
sounds. 

(a) Changes in Intensity. — This may involve both 
sounds in nearly equal proportions, or it may affect only 
one sound. Normally, the intensity of the first and 
second sounds of the heart bear a definite relation to 
each other. The intensity of the sounds may be rela- 
tively increased or diminished without indicating any- 
pathological change in the heart, as the intensity is 
largely dependent upon the degree of endocardial and 
blood pressure. The increase or diminution affecting 
both sounds should always be considered in connection 
with the tension and compressibility of the pulse. 

The cardiac sounds vary normally within certain 
limits. In the young the first sound is shorter, higher 
pitched and more ringing in character, with a greater 
prominence of the valvular element than in the adult ; 
while the second sound, heard over the pulmonic area, 
is louder than the aortic. After middle life the first 
sound is duller, more prolonged and lower pitched, the 
mitral and tricuspid elements being relatively less 
prominent, while the aortic sound becomes more accen- 



AUSCULTATION. 293 

tuated and is louder than that heard in the pulmonic 
area. 

In adult life the first sound varies greatly. "In thin, 
nervous people the first sound is high pitched, short and 
more ringing in character. In the robust and vigorous 
it is low pitched, prolonged and rambling, while in the 
fat and indolent it is indistinct and short." 

The cardiac sounds are modified (1) by those condi- 
tions which increase or diminish the conduction of the 
sounds to the surface, as (a) thickness or thinness of the 
soft parts, (b) condition of the bony thorax, (c) changes 
in the lung and pleura, (d) changes in the pericardium; 
(2) by changes in the circulatory system. 

Increase in Intensity. — Both sounds of the heart 
are increased in intensity (a) when the thorax is thinly 
covered by soft parts; (b) when the bony thorax is 
flexible and readily thrown into vibration; (c) when, 
through changes in the pleura or lungs, the heart is 
uncovered to a greater extent than normal; (d) when 
the pulmonary tissue that normally covers the heart is 
rendered more homogeneous by consolidation and the 
cardiac sounds are conveyed to the surface with a 
peculiar distinctness, the valvular element being espe- 
cially prominent. Cavities with tense walls and 
pneumo-thorax also cause increased conduction of the 
normal heart sounds. (e) Adherent pericardium 
causes increase in the cardiac sounds, due both to in- 
crease of power of conduction and to secondary changes 
induced in the heart muscle. 

Increase in intensity may be due to conditions of the 
circulatory system. 

First Bound. — The intensity of the first sound may be 
increased both in the muscular and valvular elements or 
only in one. In cardiac overaction, and associated with 
low tension in the blood-vessels, as occurs in fevers, 
physical exertion, mental and emotional excitement and 
in Grave's disease, the first sound is high pitched and 
short, and the valve element is most marked. When 



294 THE CIRCULATORY SYSTEM. 

cardiac hypertrophy is present (compensating), and 
when cardiac overaction is associated with high tension 
in the blood-vessels, the muscular element predominates 
and the sound is dull, prolonged and booming. When 
cardiac hypertrophy ceases to be compensating, the first 
sound, although more intense than normal, becomes 
short, sharp and "flapping," the valvular element being 
most pronounced. 

Second Sound. — Increase in intensity of the second 
sound of the heart may be due to the accentuation of 
both aortic and pulmonic sounds, or it may be limited 
to one sound. 

Accentuation of the Aortic Sound. — Accentuation of 
the aortic sound is usually dependent upon increased 
pressure within the aorta, which causes the valves to 
close with greater tension and suddenness than nor- 
mally. The increased pressure within the aorta may be 
transient, as when due to increased cardiac action or to 
obstruction to the now of blood from the arteries and 
capillaries, as spasm from chilling of the surface, nerv- 
ous shocks, etc. ; or it may be permanent, as occurs in 
cardiac hypertrophy with dilatation and in arterial 
sclerosis, kidney disease, etc. The aortic second sound 
is usually accentuated in pregnancy, because of the 
marked increase in blood mass. Accentuation of the 
aortic second sound is usually associated with a corre- 
sponding increase in the intensity of the first sound. 
This relation is frequently disturbed by the muscular 
power of the heart becoming insufficient, when the 
second sound becomes accentuated and the first sound 
grows progressively weaker and feebler. This associa- 
tion is always a grave symptom. 

As the aortic sound is normally weaker than the pul- 
monic sound until middle adult life, the intensitv of 
these two sounds must be compared in order to detect 
changes in the normal relative intensity. After middle 
adult life, normally, the aortic sound approaches more 
nearly that of the pulmonic, and the latter becomes more 
intense. 



AUSCULTATION. 295 

Accentuation of the Pulmonic Sound. — The sound 
over the pulmonic area is accentuated by conditions 
which raise the blood pressure in the pulmonary artery, 
as acute and chronic congestion of the lungs, acute 
inflammatory diseases, anaemia, and obstructive diseases 
of the lungs (emphysema, fibroid induration). As will 
be shown later, increased tension in the pulmonary 
artery is associated with corresponding hypertrophy of 
the right ventricle. When endo-ventricular pressure in 
the right ventricle is raised above a certain point, insuffi- 
ciency of the tricuspid valve occurs (safety-valve 
action), and there ensues a corresponding diminution 
in the accentuation of the pulmonic sound. 

Diminution in Intensity. — The cardiac sounds are 
diminished in intensity by (1) those conditions which 
interfere with conduction to the surface, as (a) when 
the thorax is thickly covered with adipose tissue; (b) 
when the bony thorax is rigid; (c) when the heart is 
separated from the chest wall by distended lung tissue 
(emphysema) or displaced by effusions into the pleural 
cavity; (d) by effusions into the pericardium and 
pneumopericardium. In these conditions the character 
of the sounds is muffled (2) by changes in the heart 

itself. 

First Sound. — The intensity of the first sound of the 
heart is diminished by all conditions of muscular feeble- 
ness, both relative, as when hypertrophy is no longer 
compensating, and absolute, as degenerations of the 
cardiac muscle. The soimd in these conditions is short, 
sharp, and the booming character is lacking and replaced 
by a peculiar "flapping" quality, dependent upon the 
valve element. 

The Second Sound. — The aortic sound is diminished 
in intensity by (1) conditions which cause low blood 
pressure, decrease in the aortic recoil, and due to (a) 
feeble heart action; (b) imperfect or slow filling of" 
the aorta, as occurs in aortic stenosis, mitral stenosis 
and mitral regurgitation ; (c) loss of blood mass from 



296 THE CIRCULATORY SYSTEM. 

hemorrhage, diarrhoea, etc., (d) or increased rapidity of 
now from the arteries and capillaries. (2) Changes in 
the valves themselves, diminishing their elasticity, as 
in endocarditis. 

The pulmonic sound varies within mnch narrower 
limits than does the aortic, as the normal pressure within 
the pnlmonary artery is more uniform. Marked dimi- 
nution in the pnlmonic second sound is generally indica- 
tive of failure of the right ventricle. 

Changes in Rhythm. — The rhythm of the heart 
may be disturbed by alterations in (1) the relative time 
of the pause. When the heart beat is increased in fre- 
quency, in proportion to the rate of the heart there is a 
corresponding shortening of the pause (diastole), be- 
tween the second and first sounds of the heart, but this 
is never sufficiently marked to disturb the normal 
rhythm. 

(2) In embryo-car dia, in which the two sounds follow 
each other at equal intervals, giving the peculiar tick- 
tack character of the foetal heart. This condition is 
generally indicative of profound muscular weakness, 
and occurs in the terminal stage of cardiac disease and 
impending cardiac failure in typhoid fever and other 
acute diseases. It is an especially grave symptom in 
typhoid fever and in Grave's disease. 

(3) Canter or Gallop Rhythm. — In this condition 
three sounds of the heart are noted. The three sounds 
may be equally distinct, or the added sound may be of a 
different character and may occur at any period of the 
cardiac cycle. The rhythm is similar to that of the 
footfalls of a galloping horse, hence the name, "gallop 
rhythm,'' or a bruit de galop." 

(Jf-) Reduplication of Sounds. — Both the first and 
second sound may be reduplicated or doubled. A slight 
degree of reduplication of the second sound is physio- 
logical, and can be induced by holding the breath. In 
this condition the temporary heightening of the pressure 
in the pulmonary artery causes tardy closure of the 



AUSCULTATION. 297 

pulmonic valves. Doubling of the first sound may also 
occur, but is usually more apparent than real. The 
most common conditions with which reduplication of the 
first sound is associated are: (1) Valvular lesions of 
the heart, especially mitral regurgitation; (2) arterial 
degeneration with raised arterial tension, and accen- 
tuated aortic second sound (arterio-sclerosis, nephri- 
tis) ; (3) pulmonary emphysema; (4) anaemia; (5) 
gastro-intestinal irritation (dyspepsia, etc.), causing in- 
creased arterial tension. To account for the reduplica- 
tion of the sounds, many theories have been advanced. 
As the reduplication seems to concern chiefly the valvu- 
lar elements of the sounds, it is evidently due to the fact 
that the time of the maximum intensity of the sounds 
made at the different valves on one side of the heart does 
not correspond to that of their fellows on the other side 
of the heart, being separated by an appreciable interval. 

Abnormal or Adventitious Sounds. Murmurs. — The 
abnormal or adventitious sounds heard over the praecor- 
dia may be produced (1) within the heart (endocar- 
dial), or (2) in the pericardium, lung or pleura (exo- 
cardial). 

Endocardial Murmurs. — Endocardial murmurs are due 
to vibrations made at the valve orifices by the movement 
of the blood through them. Normally, the blood passes 
the valvular orifices without any sound being produced 
except the normal first and second sounds. This noise- 
less passage of the blood demands (1) normal anatomi- 
cal conditions at the openings, as far as smoothness of 
surface, relation of the size of the opening, both relative 
and absolute, to the part beyond, and perfect closure of 
the opening by the valves during the normal period. 
(2) A certain specific gravity of the blood, and (3) a 
definite rapidity and force of the current. Disturbance 
of any one of these factors may be sufficient to break up 
the moving column of blood into a fluid veins'' whose 
vibrations are rapid enough to produce a sound or 
murmur when transmitted to the surface of the body. 



298 THE CIRCULATORY SYSTEM. 

Classification of the Murmurs. — Murmurs are classified 
as (1) organic or valvular, (2) inorganic or non- 
valvular. 

Organic or Valvular Murmurs.— Fluid veins are 
made whenever the blood is forced through a narrow 
portion of the circulatory tract into a part that is larger. 
In the normal heart the relative sizes of the opening and 
cavities of the heart and aorta are such that fluid veins 
are not formed under usual conditions. 

The necessary physical condition for the production 
of fluid veins may be produced by anatomical changes 
at the valve orifices which (a) interfere with the pas- 
sage of blood in normal direction through the opening, 
as narrowing of opening or roughing of the surface 
(obstruction or stenosis) ; (b) which allow of abnormal 
or backward flow (regurgitation), due to imperfect 
closure of opening, from change in valves (absolute 
insufficiency), or to dilatation of opening (.relative in- 
sufficiency), (c) At the aortic and pulmonary orifices, 
increase in the size of the vessel may so change the rela- 
tion between the size of the opening and the cavity 
beyond as to favor the production of fluid veins. 

Inorganic or Eon- Valvular Murmurs. — These 
may occur with normal cavities, orifices, and are due to 
(a) changes in the blood, lowering its specific gravity. 
This allows the fluid veins to be more readily formed in 
both normal and pathological conditions of the valves 
and orifices, and also in the great vessels'. The specific 
gravity of the blood is lowered in anaemia, hydraimia, 
and the murmurs are known as anaemic or hcemic. 

(b) Increase in rapidity and force of the current of 
blood. It is possible for the action of the heart to be 
so energetic and rapid as to produce vibrations (inor- 
ganic murmurs) at the different orifices when they are 
normal in size and structure and the specific gravity of 
the blood is unchanged. The murmurs are known as 
functional or dynamic. 

A certain amount of force is also necessary to produce 
murmurs in pathological conditions of the heart. 



AUSCULTATION. 299 

In every case of endocardial murmur one or more of 
the above factors are present in varying degree, and 
each has an influence in producing certain characteristic 
features of the murmur. 

Characteristics of Murmurs. — The recognition of an 
endocardial murmur and the determination of its orisriD 
and pathological significance depend upon its (1) 
quality, (2) intensity, (3) time or rhythm ,(4) point of 
maximum intensity, (5) area of diffusion, (6) duration, 
(7) permanency and influence of exertion and posture. 

Quality of the Murmur. — Endocardial murmurs 
vary widely in relation to their quality, and it is some- 
times difficult to determine whether or not a slight varia- 
tion from the normal sound is due to the presence of a 
murmur. All murmurs have in a greater or less degree 
a liquid character. In addition to this they may have a 
peculiar rushing or harsh, blowing sound, which may be 
imitated by the voice in pronouncing the syllables uf } 
uv, us, ushj uz; or, they may have a soft, blowing sound, 
as represented by the syllables with vowel sounds of oo, 
u, ah, au; or, again, they may have a rougher, more 
vibrant character, as in uur, orr, arr. At times the 
vibrations mav have a musical sound. 

The quality of the sound does not determine whether 
the murmur is organic or inorganic, although hamiic 
murmurs as a rule are of the soft, blowing character. 

The quality of the murmur may change from time to 
time in the individual case, depending upon the changes 
in size and structure of the orifice and valves, the rela- 
tive size and condition of the space into which the blood 
is forced, the varvino; force of the cardiac action, and the 
presence or absence of anaemia. 

Ixte:n"Sity of Murmurs.- — The intensitv or loudness 
of endocardial murmurs shows 2Teat variabilitv in 
lesions involving the different orifices or the same orifice 
and in the same case at different times. 

The intensity of a murmur depends upon (a) the 
force of the blood current, (b) the size and shape of the 



300 THE CIRCULATORY SYSTEM. 

orifice at which the murmur is made and the state of the 
cavity into which the vibrating blood is thrown, and (c) 
the condition of the blood. 

Systolic murmurs, the force being supplied by the 
ventricular contraction, are usually louder, other things 
being equal, than diastolic murmurs, whose force is due 
to the elastic recoil of the aorta and pulmonary artery. 
In pre-systolic murmurs the force is supplied by the 

auricle. 

The varying degrees of intensity are of important 
diagnostic and prognostic value, as diminution in the 
intensity is frequently the first sign of failing cardiac 
power. On the contrary, gradual increase in the inten- 
sity of the murmur may indicate gradual restoration of 
compensation. 

The size and shape of the orifice influences the in- 
tensity of the murmur according to the character of the 
vibrations produced. The narrower the orifice in pro- 
portion to the size of the cavity beyond, the more intense 
is the murmur as a rule. 

The intensity of the murmur is also influenced by the 
character of the circulating blood. When the specific 
gravity is reduced by diminution of the corpuscular 
elements or by the decrease in proteids (hydremia), the 
murmurs are louder and their quality is changed. As 
the specific gravity of the blood becomes more nearly 
normal, the loudness of the murmurs decreases. 

The intensity of the murmurs made at the different 
orifices of the heart varies considerably with the posture 
of the patient. Of murmurs made at the mitral and tri- 
cuspid orifices, the obstructive murmurs are loudest 
when the patient is sitting or standing, and become 
feebler or disappear when he is lying down. Regurgi- 
tant murmurs at these orifices, on the other hand, are 
most distinct when the patient is lying flat on the back, 
and become more indistinct as he resumes the upright 
posture. Murmurs made at the aortic and pulmonary 
valves are not influenced to the same extent by posture. 



AUSCULTATION. 301 

Aortic regurgitation is loudest when the patient is in the 
recumbent position, and is still further increased if one 
or both arms are raised above the head. Systolic 
anaemic murmurs heard over the base of the heart are 
loudest when in the recumbent position, and their in- 
tensity is also increased at the end of expiration and 
just at the beginning of inspiration. 

Time or Rhythm. — As endocardial murmurs may be 
produced at any part of the cardiac cycle, the most 
important characteristic is its relation to the normal 
cardiac sounds. As the ventricular systole is the most 
prominent phase of the cardiac cycle, being marked by 
the visible apex beat, the carotid pulse and the first 
sound of the heart, murmurs are timed by it. Mur- 
murs are described as systolic and diastolic. On account 
of the relative length of the diastolic pause, those mur- 
murs that are only heard during that portion of ventricu- 
lar diastole that immediately precedes the occurrence of 
the first sound have been named pre-systolic murmurs. 

Systolic murmurs may be (1) obstructive, as when 
produced by blood flowing in a normal direction through- 
valves that should be open at this period of the cardiac 
cycle — that is, the aortic and pulmonic valves — or (2) 
regurgitant, as when the blood is forced back through 
valves that should be closed, namely, the mitral and tri- 
cuspid valves. 

Diasystolic murmurs are (1) regurgitant, being due 
to leakage at either the aortic or pulmonary valves, 
which should normally be closed at the completion of 
systole and occurrence of the second sound. 

(2) Pre-systolic murmurs are obstructive, being 
produced at the mitral and tricuspid valves during the 
auricular systole, which immediately precedes the ven- 
tricular systole and the occurrence of the first sound. 

As the time at which the murmur occurs and its rela- 
tion to the normal sound is most important for diagnosis, 
it is necessary that it be correctly determined. Ordi- 
narily the first sound of the heart is the more easily 



302 



THE CIRCULATORY SYSTEM. 



detected than the second sound, and is used to time the 
murmnr by auscultation. But whenever it is masked by 
the occurrence of a systolic murmur, the time of the 
different phases of the cardiac cycle should be deter- 
mined by listening over the valve areas, where second 
sounds are heard with greatest distinctness. With these 
facts determined, the time of the abnormal sound can 
be fixed most readily. 

The differential stethoscope is frequently an aid in 
determining the time of a murmur, as it allows of com- 



Fig. 60. 



1st Sound 



2nd Sound 




Systolic murmur, following first sound. 



1st Sound 2nd Sound 




Systolic murmur, accompanying first sound. 



1st Sound 2nd Sound 




Systolic murmur, replacing first sound. 



parison, through the two chest pieces placed at different 
portions of the chest, of the murmur with the first or 
second sound heard at an area uninfluenced by it. 

Murmurs may accompany or take the place of the nor- 
mal heart sounds, and their duration is also measured by 
their relation to the normal cardiac periods. As the 
first sound of the heart is made up of both muscular and 
valvular elements, systolic murmurs will influence one 
or the other of these elements by accompanying it or 
replacing it, according to the changes that have occurred 



AUSCULTATION. 



303 



at the orifice and the effect of these lesions on the ven- 
tricular wall and cavity. (Fig. 60.) Diastolic mur- 
murs may accompany, take the place of, or follow the 
second sound ; and the presence or absence of the valvu- 
lar sound, and whether or not the murmur follows it, de- 
termine to a certain extent the condition of the orifice 
and of the valves themselves. (Fig. 61.) 

Poixt of MAxtMt3r Intensity and Atjea of Dif- 
fusiox. — The point at which a murmur is most dis- 
tinctly heard determines the orifice at which it is made. 



Fig. 61. 



1st Sound 



2nd Sound 



1st Sound 




Diastolic murmur, following second sound. 



.1st Sou n d 2n d So u n d 






lst Sound 



Late diastolic murmur. 



1st Sound 2nd Sound 



1st Sound 





Pre-systolic murmurs. 



The points of maximum intensity of the endocardial 
murmurs do not correspond to the anatomical site of the 
valves nor entirely to the valve areas. The conductiou 
of murmurs to their points of maximum intensity is 
dependent (a) on the direction of the blood current 
which produces the murmur, and (b) on the readiness 
with which certain portions of the heart, by reason of 
their anatomical relations, transmit the vibrations made 
at the point of obstruction or regurgitation to the sur- 
face. 



304 



THE CIRCULATORY SYSTEM. 



From the point of maximum intensity, the murmur 
is transmitted in different directions (area of diffusion). 
The extent and direction of the transmission are vari- 
able, chiefly according to (a) the strength and character 
of the vibration producing the murmur ; (b) the method 
of primary conduction to the surface, whether mainly 
by blood current or solid structures (heart, lung, etc.), 
and (c) to the diffusion over the chest from the point of 
maximum intensity by the bony thorax and soft parts. 
It is necessary to consider the point of the maximum 
intensity and area of diffusion of the murmurs made at 
the different orifices. 

Fig. 62. 




Mitral pre-systolic murmur. Apex of heart. 

Murmurs Made at the Mitral Orifice. Mitral Pre- 
systolic Murmurs. — The point of maximum intensity 
is slightly to the right of the apex of the heart (left 



AUSCULTATION. 



305 



ventricle) 7 whether it is in the normal position or dis- 
placed, and its area of diffusion is, as a rule, very 
slightly beyond the region of the apex. (Fig. 62.) 
The localization of a murmur at the region of the apex 
of the left ventricle is due (a.) to the direction of the 
vibrating blood current, which is concentrated at the 
apex by the valves of the narrowed orifice, (b) The 
flaccid condition of the overlying right ventricle pre- 



Fig. 63. 




' Mitral obstruction. Large arrow direction of current of blood. 

vents the transmission of the vibrations to the surface 
In that direction, (c) The left ventricle being also in a 
state of relaxation and at its greatest distance from the 
chest wall, the vibrations, conducted to the surface 
through the overlying lung, influence a very small area 
of chest. (Fig. 63.) m 

A wider area of diffusion of the pre-systohc mitral 
murmur is generally due either to unusually close rela- 

20 



306 



THE CIRCULATORY SYSTEM. 



tion of the apex of the left ventricle to the chest wall, or 
to increased power of conduction on the part of the tis- 
sues surrounding the apex of the heart, or to the 
character of the vibrations. 

The pre-systolic murmur heard at the apex is gener- 
ally due to obstruction at the mitral orifice, although 
murmurs with this rhythm and localization without 

Fig. 64. 




Mitral systolic. 

mitral obstruction have been heard in aortic regurgita- 
tion (Flint murmur), in aortic obstruction and with 
adherent pericardium. 

Mitral Systolic Murmurs. — The point of maxi- 
mum intensity is at or close to the apex. The area of 
diffusion extends also around this point, and to the left 
beyond the prsecordia into the axillary region. (Fig. 
64.) The murmur is also heard in the back, the point 



AUSCULTATION. 



307 



of maximum intensity being in the left interscapular 
space, a little above the angle of the scapula, opposite 
the spines of the fifth and sixth dorsal vertebra?. (Fig. 
65.) The area of diffusion is usually limited to the left 
scapular and interscapular regions. 



Fig. 65. 




Mitral systolic. 



The murmur made at the mitral valve (situated 
behind the left half of the sternum at the level of the 
fourth costal articulation) reaches the surface in front 
over the apex of the heart and behind in the scapular re- 
gion by two different lines of conduction. (Tig. 66.) 



308 



THE CIRCULATORY SYSTEM. 



Conduction to the apex is mainly by the tissues of the 
left ventricle, which at the time of the first sound of the 
heart are in a state of extreme tension. The vibrations 
made by the regurgitant stream are transmitted (a) by 
the leaflets of the mitral valve through the tense chordsea 
tendinese and papillary muscle to the apex of the left 
ventricle, (b) The apex of the left ventricle at this 

Fig. 66. 




Mitral regurgitation. Large arrow shows direction of current of 
blood. Small arrows show conduction of vibration to the apex by 
chordae tendineae and papillary muscles. 

time is in closer contact with the chest wall, to which it 
transmits the vibrations of the murmur, (c) From the 
point of contact (the point of maximum intensity) the 
vibrations are conveyed along the ribs in all directions 
(diffusion). Over the prsecordia they are deadened by 
the right ventricle, so that their diffusion to the right 
and upwards- is limited. The vibrations are conveyed 



AUSCULTATION. 309 

by the ribs to the axillary region. The murmur is 
heard over wider area when the left ventricle is much 
hypertrophied, and the apex is displaced downward and 
to the left, and is in contact with the chest wall to a 
greater extent. (Fig. 76.) 

Conduction of the mitral regurgitant murmur to the 
scapular region is from the left auricle, which is thrown 
into vibration by the stream of regurgitant blood. From 
the auricle the vibrations are transmitted through the 
overlying tissues to the surface. The mitral regurgitant 
murmur heard in the back corresponds more nearly to 
the anatomical site of the valve. 

Mitral systolic murmurs may occur in mitral insuffi- 
ciencv, due to acute or chronic endocarditis, causing 

t/ 7 7 O 

deformity of the leaflets, imperfect contraction of the 
left ventricle, or to dilatation of the left ventricle en- 
larging the mitral orifice and causing relative insuffi- 
ciency of the leaflets to close the opening. (See chapter 
XII.) 

Murmurs Made at the Aortic Orifice. Systolic Mur- 
murs. — The point of maximum intensity as a general 
rule is situated over the manubrium sterni, and not at 
the second right cartilage (aortic area). The area of 
diffusion is upward into the carotids, and laterally along 
the clavicles and over the subclavian arteries. Conduc- 
tion is by the current of blood in aorta to the point of 
maximum intensity. The vibrations are transmitted 
through the walls of the aorta to the manubrium sterni 
and clavicles. (Fig. 67.) 

Systolic murmurs in the aortic region may be caused 
by conditions that lead to the production of vibrations 
at the valve orifice itself or in the aorta just beyond. 
At the orifice: (1) Narrowing of the lumen of the 
opening by changes in the valves (stenosis) (2) 
Roughening of the surfaces by vegetations, calcareous 
deposits without diminution in the size of the orifice 
(non-stenotic). In the aorta: (1) Roughening of the 
inner walls of the aorta. (2) Dilatation of the aorta. 



310 



THE CIRCULATORY SYSTEM. 



Inorganic causes: (1) Functional or dynamic, due to 
increase of cardiac force, as in cardiac overaction caused 
by mental or emotional excitement, physical exertion, 
Grave's disease. (2) Hsemic or anaemic. 

Murmurs due to anaemia are heard in the aortic area 
or over the sternum, but are transmitted into the vessels 
of the neck with increasing intensity. 

Fig. 67. 




Aortic obstruction. 



Aortic Diastolic Murmurs. — The point of maximum 
intensity is not, as usually described, at the second 
right intercostal cartilage, but over the sternum and at 
the left edge, opposite the third interspace or fourth 
costal cartilage. The area of diffusion is downward 
along the sternum, and also to the apex of the left 
ventricle. (Fig. 68.) Conduction of the aortic regurgi- 



AUSCULTATION. 



311 



tant murmur to the sternum at the point of maximum 
intensity is due to the intimate relation of the aortic 
cusps with the auric ulo-ventricular septum of the right 
side of the heart. The vibrations made by the regurgi- 
tant stream are transmitted from the aortic valves 
through the right auriculo-ventricular septum to that 
portion of the sternum that is in closest contact with it, 
viz. : from the third left interspace to the sixth rib on 

Fig. G8. 




Aortic regurgitation. 

the right side. Conduction of the murmur to the apex 
of the left ventricle is by the regurgitant stream. (Fig. 
69.) The character of the murmur heard at the apex 
may differ greatly from that present over the sternum. 
Variations in the location of the point of maximum 
intensity and area of diffusion are dependent upon the 
cause and the nature of the secondary changes in the 
heart and aorta. (See Aortic Eegurgitation. ) 



312 



THE CIRCULATORY SYSTEM. 



Regurgitation at the aortic orifice may depend upon 
(a) absolute insufficiency of the valves, due to vegeta- 
tions, loss of substance, thickening and distortion of the 
valves, congenital malformation (rare) ; (b) upon rupt- 
ure of the valves; (c) upon relative insufficiency, as 
when the valves are normal, but insufficient to close the 
orifice on account of dilatation of the aortic ring. 



Fig. 69. 




Aortic regurgitation. Arrows show lines of conduction of vibrations. 



Murmurs Made at the Tricuspid Valve. — Tricuspid 
murmurs are usually most distinct over the lower por- 
tion of the sternum and along the lower left costal 
cartilages. 

Tricuspid Pre-systolic Murmurs. — The point of 
maximum intensity is over the lower portion of the 
sternum, at the upper edge of the ensiform cartilage, 
and the area of diffusion corresponds with the area of 



AUSCULTAT10X. 



313 



superficial cardiac flatness. (Fig. 70.) Conduction 
to the surface of the vibrations made at the tricuspid 
valve is from that portion of the right ventricle which is 
in direct contact with the sternum. 

The tricuspid pre-systolic murmur is extremely rare, 
and, when detected, is diagnostic of obstruction at the 
orifice, either congenital or acquired. 

Fig. 70. 




Tricuspid obstruction. 



Tricuspid Systotjc Murmurs. — The point of maxi- 
mum intensity is at the base of the ensiform cartilage, 
and the area of diffusion from the point of maximum 
intensity is upward and to the right, not above the third 
rib, and to the left toward the apex of the heart, (Fig. 
71.) Conduction of the murmur in these two direc- 
tions is by the regurgitant stream, and by transmission 



314 



THE CIRCULATORY SYSTEM. 



through chordae tendinese to apex, the same is in. mitral 
regurgitation. 

Vibrations made at the valve are carried by the 
regurgitant current of blood upward into the auricle 
over which the murmur is heard. The vibrations are 
transmitted to the right ventricular wall by the attach- 
ment of the valve and by the tense chord se tendinere and 

Fig. 71. 




Tricuspid regurgitant. 

papillary muscle. The point of maximum intensity and 
the area of diffusion vary according to the degree of 
hypertrophy and dilatation. At times the murmur cor- 
responds in location to the mitral area. It is rarely 
heard beyond the praecordia, and is not carried into the 
axilla nor heard behind in the scapular region. 

Eegurgitation at the tricuspid orifice results from 



AUSCULTATION. 



315 



insufficiency due to (a) the effects of acute and chronic 
endocarditis, to vegetations, to induration or distortion 
of the valves, and to shortening of the chordae tendineae ; 
(b) from dilatation of the right ventricle and tricuspid 
ring, with relative insufficiency. The dilatation may be 
permanent or transient (safety-valve action). (See Re- 
gurgitation at Tricuspid Orifice.) 

Fig. 72. 




Pulmonic systolic — stenotic. 

Murmurs at the Pulmonary Orifice. Pulmonic Sys- 
tolic Murmurs. — The point of maximum intensity is 
at the left intercostal space, close to the sternum. The 
area of diffusion may be circumscribed around the point 
of maximum intensity, or may extend upward along the 
course of the pulmonary artery and laterally to the left. 
(Fig. 72.) 



316 



THE CIRCULATORY SYSTEM. 



The occurrence of a systolic murmur at the pulmonic 
area is extremely common, and may be due (a) to 
organic changes in the valves, producing obstruction 
(rare), or (b) to narrowing of the lumen of the pul- 
monary artery by changes in the surrounding structures 
or torsion from displacement of the heart; (c) to 
anaemia, either alone or associated with dilatation of the 

Fig. 73. 




Pulmonic systolic anaemic murmur. 

artery (most commonly). In anaemic murmurs the 
point of maximum intensity and area of diffusion is 
more variable than in those dependent on stenosis at 
orifice. (Figs. 73 and 74.) 

Pulmonic Diastolic Murmurs. — This murmur is 
very rare. The point of maximum intensity is over the 
pulmonic valve area. The area of diffusion is along the 



AUSCULTATION. 



31' 



left edge of the sternum. It may occur (a) from con- 
genital malformation or ulcerative endocarditis; (b) 
from relative insufficiency caused by dilatation of the 
pulmonary artery or orifice. (Fig. 75.) 

Exocardial Murmurs. A. Arterial Murmurs. — The 
presence over the aorta of the normal cardiac sounds, and 
of murmurs made at the aortic orifice and in aorta, has 

Fig. 74. 




Anaemia, pulmonic systolic. 



already been mentioned, and will be still further consid- 
ered under diseases of the aorta. 

When the stethoscope is lightly applied to the carotid 
and subclavian arteries the normal first and second 
cardiac sounds may be faintly heard; the first sound 
weak and low pitched, the second sound louder, higher 
pitched and snapping, corresponding to its character 



318 



THE CIRCULATORY SYSTEM. 



at the aortic cartilage. Over the arteries that are 
further removed from the heart, as the brachial, crural, 
femoral, etc., no sound is normally heard unless the 
pressure of the stethoscope is sufficiently hard to com- 
press the artery, when there is heard a systolic mur- 
mur ("pressure murmur"), whose intensity corresponds 
to the degree of narrowing, and which may have a 
musical quality. 

Fig. 75. 




Pulmonic diastolic. 



Murmurs heard over the arteries may be produced 
(a) at the cardiac orifice or aorta, and conducted into 
them, or (b) in the blood-vessels at the point where 
heard. 

Systolic murmurs made in the arteries mav be due 
(a) to roughening of the inner coat ; (b) to narrowing of 
the lumen, which may be caused by changes in the wall 



AUSCULTATION. 319 

of the artery, as calcareous plates, or due to pressure 
from surrounding structures, as lymph nodes, etc. ; (c) 
to dilatation of the vessel from fever, acute local in- 
flammation, chronic dilatation and vaso-motor condi- 
tions, causing paresis of the vessel itself at certain 
points ; ( d) to anaemia. Two or more of these causes 
may be combined in any given case. The association of 
localized vaso-motor dilatation with anaemia is particu- 
larly common. 

Over the subclavian arteries a short, blowing, systolic 
murmur ("whiff") is normally heard when the chest is 
fully expanded. This murmur may become constant 
and harsher if the artery is contracted or a sharp bend 
produced by retraction of the apex of the lung o~ 
pleural adhesions. This subclavian murmur is fre- 
quently mistaken for an aneurismal murmur. 

Diastolic murmurs may be heard in the arteries in 
cases of extensive aortic regurgitation. In rare cases a 
double murmur has been heard in the femoral artery in 
pregnancy without aortic regurgitation. The statement 
has been made that it also occurs in lead poisoning and 
in mitral stenosis. 

B. Venous Murmurs. — A murmur or humminsr 
sound may be heard over the great vessels above the 
clavicles behind the sterno-cleido-mastoid muscle in 
about fifty per cent, of young persons, the frequency 
diminishing with age. The occurrence of a murmur at 
this site is due to the sharp bend forward in the internal 
jugular vein and its relation to the omohyoid muscle 
(Hamernyk). This murmur is continuous, and varies 
in intensity. It is loudest during and immediately 
after auricular diastole, during inspiration and when 
the patient is sitting or standing, as at this time the 
current in the veins is strongest. It becomes very faint 
or disappears entirely when the patient is recumbent. 
It is loudest on the right side of the neck, and is in- 
creased by slightly turning the head to the left. 

In anaemic conditions this physiological murmur be- 



320 THE CIRCULATORY SYSTEM. 

comes constant, intensified, and in quality more musical. 
It may also be induced by slight pressure over the veins 
in other regions of the body. The anaemic venous hum 
(bruit du diable) is differentiated from the arterial 
murmur by being continuous, and the intensity not 
varying with systole of the heart. When communica- 
tion occurs between the artery and the vein (arterial 
varix), a systolic murmur is heard over the area in- 
volved. 

Sounds Made in the Pericardium. — Normally, the ser- 
ous surfaces covering the heart move noiselessly. When 
the surfaces are roughened audible vibrations are made, 
and the sound is recognized as pericardial by (a) its 
character, (b) its time, (c) its localization and trans- 
mission, (d) modifications that occur by posture and 

pressure. 

The character of the pericardial friction sounds may 

simulate very closely the endocardial murmurs, but 

J usually they are of a rubbing, scratching, rasping or 

scraping quality. Friction sound, although dependent 
upon cardiac action, may not coincide in rhythm with 
the different phases of the cardiac cycle, extending as a 
single sound beyond the period of systole or diastole. 
It may occur as a to-and-fro (double) sound, due to the 
motion of both ventricular systole and diastole, or it 
may even have a triple rhythm, due to auricular as well 
as the ventricular action. 

The friction sound may present variations in rhythm 
and quality over different portions of the prsecordium, 
and those having a murmurish quality may lead to the 
diagnosis of endocardial murmur. 

Pericardial friction sound is limited to the precordial 
space, although rarely heard over the entire peri- 
cardium, even in general inflammation of the sac. It 
may be heard over that portion of the pericardium that 
is reflected over the base of the aorta, and be detected as 
high as the second interspace and as far as the left 
nipple. The point of maximum intensity is usually 



AUSCULTATION. 321 

over the base of the heart, in the third and fourth inter- 
spaces. 

The important diagnostic feature of pericardial 
sounds is that they give the impression of being made 
close to the surface, and that their intensity and char- 
acter may be modified by posture. AVhen the body is 
thrown forward so that the heart is in closer contact 
with the anterior portion of the pericardium, the sounds 
become more distinctly frictional in character, which 
lessens as the patient resumes the upright position, and 
may be absent when he is recumbent. Firm pressure 
with the ear or stethoscope over the prsecordia also in- 
creases the intensity of the sound. 

Pericardial friction sounds vary in character and 
location from time to time, according to the nature of 
the changes in the sac. 

Pleuro-Pericardial Friction Sounds. — Pleuro-pericardial 
friction sounds may be heard over that portion of the 
pleura that overlaps the heart. This sound is most fre- 
quently heard in the fourth and fifth intercostal spaces. 
The quality and rhythm of this friction sound may 
correspond with that made in the pericardium, but the 
rhythm is disturbed by the respiratory movements, dis-- 
appearing with full inspiration and recurring with ex- 
piration. 

Cardio-Pulmonary Sounds — A blowing sound, as of a 
murmur, may be produced by cardiac action in the layer 
of lung that is interposed between the heart and the 
chest wall. It is due to the impact of the heart forcing 
air out of the alveoli with sufficient force to produce a 
localized respiratory murmur or puftX^rdio-respiratory 
murmur). It is heard most frequently over the apex 
of the heart and along the left border of relative cardiac 
dullness, and is not transmitted into the area of cardiac 
murmurs heard in the same locality. Although caused 
by cardiac action, the murmur is not always synchronous 
with the cardiac sounds ; it may be heard during systole 
and for a short time after the occurrence of the second 
21 



322 THE CIRCULATORY SYSTEM. 

sound. The intensity of the murmur is variable, and is 
affected chiefly by the respiratory movements, and also 
by the posture of the patient. It may be loudest either 
during inspiration or expiration, or may be present only 
when the lungs are fully inflated and the breath is held. 
At times, instead of being heard with each heart beat, it 
is only detected with each fourth beat, its rhythm being 
determined by the respiratory cycle. 

Its intensity may be increased by firm pressure with 
the ear of stethoscope over the prsecordia. 

When the air-vesicles and bronchioles' contain secre- 
tion, the cardiac respiratory murmur may be attended 
with fine crackling or moist rales. 



CHAPTEE XII. 

DIAGNOSIS OF DISEASES OF THE HEART. 
VALVULAR LESIONS. 



REGURGITATION AT THE MITRAL ORIFICE. 

Regurgitation at this orifice is the most frequent of 
all valvular lesions, and at the same time that most 
compatible with good physical health. 

Normally, competency at the mitral valve is de- 
pendent upon (a) perfect coaptation of the valve 
leaflets; (b) control over the position of the valve 
leaflets through the chordae tendinese by the papillary 
muscle; (c) contraction of the muscle of the ventricle, 
which reduces the area of the auriculo-ventricular open- 
ing to one-half the size that it has during ventricular 
diastole, and also changes the shape from a circular to a 
somewhat oval form. 

Incompetency may be due to disturbance in manner 
or time of one or more of these co-ordinatiiiff factors. 
Coaptation of the mitral leaflets may be interfered with 
(1) by swelling or vegetations (acute or subacute endo- 
carditis), (2) by loss of substance (ulcerative endocar- 
ditis), (3) by thickening, shriveling or distortion, or 
binding together in a manner to prevent closure (the 
result of previous endocarditis). (4) The fibrous ring 
to which the valve is attached mav be so thickened as to 
interfere with the action of the valves. ( 5 ) The chorda 3 
tendinese may be stretched, thickened or distorted. (6) 
The papillary muscles may fail to exert the right 
amount of traction at the right time on the chordae 



324 THE CIRCULATORY SYSTEM. 

tendinese from weakness of the muscles or change (dila- 
tation) of the ventricular cavity. (7) The size of the 
auriculo-ventricular orifice may not be sufficiently con- 
tracted at the time of systole, on account of fibrous 
thickening of the ring at the base of the valves, flabbi- 
ness of the cardiac muscle or dilatation of the left ven- 
tricle. In this latter condition the valves, though 
normal, are insufficient to close the opening (relative 
valvular insufficiency). 

Insufficiency at the mitral orifice, due to dilatation of 
the ventricular cavity, is a frequent secondary lesion in 
primary aortic stenosis or regurgitation. Imperfect 
ventricular contraction and dilatation of the ventricular 
cavity may be caused by anaemia, and by acute ^ or 
chronic wasting diseases when associated with physical 
exertion or high blood pressure in the aorta. 

Effects of Mitral Regurgitation.— The effects of mitral 
regurgitation are both immediate and remote, and vary 
in degree according to the amount of blood that is 
regurgitated into the auricle, the force of the current, 
and the extent to which the disturbance of function at 
the mitral orifice is compensated for. The changes in- 
duced by this lesion can be divided into three stages, 
according as (1) they are limited to the left auricle and 
ventricle; (2) as they extend beyond the left auricle 
and involve the pulmonary circulation and right ven- 
tricle; (3) when failure of compensation by the right 
ventricle occurs, with regurgitation at the tricuspid 
valve and interference with venous circulation. 

First Stage. Compensation by Left Auricle 
and Ventricle. — The earliest effect of regurgitation 
is to dilate the auricle, which receives the blood from 
two sources : (1) Normal, the flow from the pulmonary 
vein; (2) abnormal, flow from the left ventricle through 

the mitral valve. 

The increased amount of blood received into the 
auricle during diastole increases its work during systole, 
and hypertrophy occurs ; and, as the dilated and hyper- 



DISEASES OF THE HEART. 325 

trophied auricle throws more blood than normally into 
the ventricle during its diastole, the ventricle also 
dilates and meets the increased demands upon it by 
hypertrophy. In this stage the compensation is through 
the dilatation and hypertrophy that occurs simultane- 
ously in both left auricle and ventricle. If the amount 
of regurgitant blood is not large there is no inter- 
ference with pulmonary circulation ; neither is the blood 
forced back into the pulmonary veins during auricular 
systole, as the openings of the veins are closed, as in the 
normal condition, by muscular contraction, and conse- 
quently the effects of regurgitation are limited to the 
left auricle and ventricle. 

Second Stage. Compensation my Right Ven- 
tricular Hypertrophy. — When the amount of 
regurgitant blood is large and the force of the currenl 
strong enough, dilatation of the left auricle occurs 
beyond the power of compensation. The auricle is 
quickly filled by the blood from the ventricle, and, as 
the pressure in the pulmonary veins is normally low, the 
flow of blood from the lung is interfered with, and con- 
gestion occurs. This congestion causes interference 
with the flow of blood through the capillaries and raises 
the blood pressure in the pulmonary artery, which in 
turn causes the pulmonary valves to close with greater 
tension, and induces hypertrophy of the right ventricle 
as its work is increased, having to empty itself against 
the raised pressure in the pulmonary artery. The 
hypertrophy of the right ventricle compensates for the 
lesion at the mitral orifice, and increases in degree up to 
a point which depends upon the nutrition of the heart 
muscle and the strength of the tricuspid valves. 

Third Stage. Failure of Right Ventricular 
Compensation. — When pressure in the pulmonary 
artery becomes raised to a certain point, compensation 
by the right ventricle may fail in two ways: (1) The 
tricuspid valve may yield to the high endocardial 
presssure (safety valve action), (2) or the muscular 



326 THE CIRCULATORY SYSTEM. 

power of the right ventricle being insufficient to over- 
come the pressure in the pulmonary artery, the ventricle 
only partially empties itself during systole. At the next 
auricular systole it is overdistended by the blood re- 
ceived in addition from the right auricle. The dilata- 
tion of the right ventricular wall increases the auriculo- 
ventricular opening, which becomes too large ^ to be 
closed by the tricuspid valves (relative insufficiency). 
Incompetency at the tricuspid orifice relieves the work 
of the right ventricle, but causes interference with 
venous circulation, resulting in passive congestion of the 
abdominal organs, and later, effusion into the serous 
sacs and cellular tissue. 

Physical Signs. Inspection. — The signs noted on 
inspection correspond to the effects produced by the 
lesion upon the heart and to the secondary changes in 
the lungs and in the pulmonary, venous and arterial cir- 
culations. The severity of the lesion is estimated by the 
extent of these changes. 

First Stage. — When the amount of regurgitation is 
slight, inspection may be negative, or dilatation and 
hypertrophy of the left ventricle may cause the visible 
apex beat to be displaced slightly downward and to the 
left. When mitral regurgitation occurs early in life, 
the apex may be carried to the left nearly as far as the 
anterior axillary line, and there may be bulging of the 
prrecordia. 

Second Stage. — According to the degree of right- 
side cardiac hypertrophy, the area of the apex beat is 
increased. It is seen farther to the left, and also oyer 
the lower portion of the prsecordia toward the median 
line and in the epigastrium. In marked dilatation and 
hypertrophy of the left auricle, pulsations may be 
present at the second left interspace, dependent upon 
the systole of the auricle. This auriculo-ventricular 
systole may impart a wave-like motion, from above 
downward, to the prsecordia. 

Third Stage. — When compensation, through hyper- 



DISEASES OF THE HEART. 327 

trophy of the right ventricle, fails, and dilatation re- 
sults, a diffused cardiac impulse is present over the 
entire lower portion of the left side of the thorax, and 
also in the epigastrium. In extreme dilatation of the 
right ventricle, pulsations may be seen from the third 
to the sixth interspaces near the sternum on the left 
side, and in the epigastrium along the border of the ribs. 
Tricuspid regurgitation and dilatation of the right 
auricle may cause pulsations to be seen in the fifth right 
interspace along the sternum, and systolic pulsations in 
the veins of the neck. 

Involvement of the lungs is shown by cyanosis, 
dyspnoea (orthopnoea) ; venous stasis by enlargement of 
the abdomen (ascites), changed respiratory movements 
(hydrothorax) and oedema of the extremities. 

Palpation. — The character of the cardiac action 
detected by palpation corresponds with that noted by 
inspection. 

First Stage. — When dilatation of the left ventricle is 
slight, the apex beat, in addition to being displaced to 
the left and slightly downward, is strong, and the point 
of contact is well defined. In proportion to the dilata- 
tion and hypertrophy, the strength of the impulse is in- 
creased and heaving in character, while the area becomes 
enlarged. ]STo thrill will be felt unless mitral regurgita- 
tion is associated with stenosis. 

Second Stage. — The impulse over the lower portion of 
the prrecordia is forcible, and the area is diffused, but 
not so well defined. 

Third Stage. — With failure of right-side compensat- 
ing hypertrophy, the impulse becomes more diffused. 
When dilatation predominates it has a wave-like, indis- 
tinct character, and may be detected to the right of the 
sternum and in the epigastrium. 

The pulse in the first stage shows no alteration. In 
the second stage it may become very irregular. With 
failure of the right heart (third stage), the arteries may 
be improperly filled, and the pulse becomes small and 
irregular in force and frequency. 



328 THE CIRCULATORY SYSTEM. 

When incompetency of the tricuspid valve occurs 
the liver will be found enlarged and extending below the 
free border of the ribs. In extreme cases it will be 
pulsating. Examination of the abdomen will show 
ascites, and effusion into the pleural cavities will cause 
enlargement of the lower portion of the thorax, with 
loss of respiratory movements. 

Percussion. First Stage. — Percussion shows but 
slight increase in the area of cardiac dullness. In hyper- 
trophy and dilatation of the left ventricle alone, the 
outline of dullness over the apex is pointed. 

Second Stage.— With, hypertrophy of the right ven- 
tricle, the area of cardiac dullness is increased to the 
left at the level of the fourth rib, and the outline at the 
apex becomes rounded. 

Third Stage.— With, dilatation of the right ventricle 
and tricuspid regurgitation there is increase in the upper 
border of flatness at the level of the fourth rib, and 
dullness may be detected to the right of the sternum at 
this point. Over the lower portion of the sternum there 
may be diminution of the sternal resonance ; at the apex 
dullness extends to the left and downward. 

Pulmonary Resonance. — In the first and second stages 
the pulmonary resonance is not impaired. In the third 
stage, oedema of the base of the lungs may cause a 
diminished resonance. In the later stages, with effusion 
into the pleural cavity (hydrothorax), flatness is present 
over the lower portion of the chest. The percussion 
area of the liver is also increased. 

Auscultation. — The distinctive sign of regurgita- 
tion at the mitral orifice is a murmur which occurs with 
the ventricular systole, accompanies, replaces or follows 
the first sound of the heart (Fig. 60), having its point 
of maximum intensity at or near the apex, and is 
diffused in all directions, especially to the left, to the 
axillary line or beyond. Posteriorly it may be heard in 
the left interscapular space, just below spine of scapula. 
(Pigs. 64 and 65.) 



DISEASES OF THE HEART. 



329 



The quality of the murmur is variable. It may be 
harsh, high pitched and whistling in character, or soft, 
low pitched and blowing. Some claim that it always 
has a more or less musical quality. It also changes 
from time to time, and is influenced by posture, being- 
most marked when the patient is in the recumbent 
position. 

Fig. 76. 




Mitral regurgitation, second stage. 
X-Ray tracing of outline of the heart 

The quality and intensity of the murmur do not indi- 
cate the extent nor character of the lesion, which are 
estimated by the effect upon the heart and changes in the 
normal cardiac sounds, and in the circulatory system. 

First Stage. — In slight regurgitation a murmur may 
not be present, but the first sound of the heart at the 



330 TBE CIRCULATORY SYSTEM. 

apex may be prolonged, due to change in the valvular 
element (impure first sound). When a murmur accom- 
panies the first sound which retains its valvular element, 
the amount of regurgitation is small. The distinguish- 
ing sign of this stage is the absence of accentuation of 
the second sound of the heart in the pulmonic area, with 
a normal intensity of the aortic sound ; also the absence 
of right-side ventricular hypertrophy. 

Second Stage. — On the other hand, accentuation of 
the pulmonic second sound is a characteristic sign of 
compensation of the mitral lesion by hypertrophy of the 
right ventricle. It has been claimed that the diagnosis 
of mitral regurgitation cannot be made unless this ac- 
centuation of the pulmonic second sound is present. 

In estimating the extent of the lesion by the accentua- 
tion of the pulmonic second sound and its relation to the 
aortic, the age of the patient should always be taken into 
consideration, also whether increased tension in the pul- 
monary artery is due to obstructive pulmonary disease. 
(See page 295.) 

When right-side ventricular hypertrophy compensates 
for the lesion at the mitral valve, the murmur retains a 
fairly definite quality, intensity and duration ; also aus- 
cultation of the lungs does not show evidences of pulmo- 
nary oedema, although the breath sounds may be harsher 
than normal. 

Third Stage. — With failure of compensation the 
murmur at the apex becomes less intense. Its transmis- 
sion to the left is less marked, while the occurrence 
of tricuspid regurgitation causes the murmur to he 
heard over a wider area to the right, it often being 
impossible to separate these two murmurs : at the same 
time the pulmonic second sound diminishes in intensity. 
The mitral murmur in some cases may entirely dis- 
appear, the tricuspid murmur only being heard. In 
proportion to the failure of compensation the physical 
signs of pulmonary oedema and effusion into the pleural 
cavities occur. 



DISEASES OF THE HEART. 



331 



Diagnosis of the Pathological Condition. — The nature of 
the lesion at the mitral orifice cannot be determined by 
the physical signs alone, although these may be in a 
measure distinctive. When incompetency is due to a 
recent endocarditis there is very little change in the 
size of the heart, and the murmur is of a soft, blowing 
quality. When the valves are distorted, thickened, or 

Fig. 77. 




Anaemia — systolic murmur in mitral area. 

perfect coaptation prevented by contraction of the 
chordae tendinese, due to a previous endocarditis, the 
effect upon the left and right heart is more marked, and 
the murmur has a harsh, rough and more musical 
quality. 

According to the degree of interference with the 
valves, the murmur replaces the valvular element of the 
first sound at the apex. 



332 THE CIRCULATORY SYSTEM. - 

Incompetency due to dilatation of the left ventricle 
(relative valvular insufficiency) rarely gives a loud, 
high-pitched murmur. When this condition is secondary 
to disease of the aortic orifice, or changes in the arterial 
system, the mitral murmur is much less intense than 
those at the aortic orifice. Age is an important factor 
in determining the nature of the lesion. Under forty 
years of age, uncomplicated mitral regurgitation is 
generally due to a previous endocarditis. Occurring 
after forty-five years of age, it is generally due to 
secondary dilatation, and is associated with the history 
and physical signs of the primary lesion at aortic orifice 
or in arteries (arterio-sclerosis). 

Functional and Hcemic Murmurs in the Mitral Area. 
— Murmurs with the first sound at the apex, that occur 
in anaemia or severe febrile diseases, are generally soft, 
blowing in quality, and are not associated with 
secondary changes in the heart or pulmonary circulation. 
(Fig. 77.) The apex beat is not displaced; the force is 
weak, not lifting; the second sound over the pulmonic 
area is not accentuated, . although there may be a soft, 
blowing murmur (Fig. 78), and the tension of the radial 
pulse is unaffected. 

Murmurs of similar character may occur during acute 
febrile diseases, especially rheumatism, and be due to 
acute endocarditis affecting the mitral valve, or to tem- 
porary insufficiency resulting from cardiac muscular 
weakness (myocarditis). It is impossible to determine 
whether these murmurs are organic or functional at first 
examination, and their nature can only be decided by 
noting the changes that occur in the murmur and the 
effect on the heart and circulation. 

Aortic stenosis may be attended by a murmur that is 
heard at the apex, with a quality different from that 
present at the base of the heart, and simulating the 
murmur of mitral regurgitation. This murmur is not 
transmitted to the axilla nor associated with accentua- 
tion of the pulmonic second sound. 



DISEASES OF THE HEART. 



333 



Differential Diagnosis. — Exo-cardial murmurs may 
simulate those of mitral regurgitation. Pericardial 
friction sound may be localized at the apex, and be 
synchronous with the first sound of the heart. It is 
differentiated from the endocardial murmur by changes 
in the intensity and character caused by pressure and 

Fig. 78. 




Anaemia, systolic murmur in mitral and pulmonary areas. 

position, and it is not transmitted beyond the apex beat 
nor heard behind in the interscapular space. 

Pleuritic friction sounds generally have more or less 
of the friction quality, and are influenced also by 
pressure and position, and their rhythm is more de- 
pendent upon respiratory than cardiac action. 

Cardiorespiratory murmurs are also influenced by 



334 THE CIRCULATORY SYSTEM. 

the respiratory movements, being intensified during in- 
spiration and generally inaudible at the end of expira-* 
tion. The point of maximum intensity does not corre- 
spond to the apex of the ventricle, but is somewhat 
removed from it. The murmur does not replace the 
first sound of the heart nor change its valvular character. 
It is also influenced by the position of the patient, being 
most marked in the recumbent position, although this is 
not an invariable rule. 



STENOSIS AT THE MITRAL ORIFICE. 

Obstruction at the mitral orifice may occur as an 
isolated lesion, but it is usually associated with regurgi- 
tation. 

Normally, with ventricular diastole the mitral orifice 
enlarges to twice the size that it has during systole, and 
the relaxation of the papillary muscles allows free open- 
ing of the leaflets. The flow of blood through the 
opening is due to three forces that are operative at 
different periods of the ventricular diastole: (1) The 
aspirating or suction force of the dilating ventricle. 
This force is most marked during the first period of 
ventricular diastole, and gradually decreases as the 
ventricle becomes distended. (2) Pressure of blood in 
the auricle and pulmonary veins. This is most marked 
also at the beginning of diastole. (3) Auricular sys- 
tole, which completes the emptying of the auricle, and 
occurs just before the first sound of the heart. 

Narrowing of the mitral orifice may be due to changes 
that involve the auriculo-ventricular ring, interfering 
with the normal enlargement of the opening during 
diastole, or they may involve the leaflets or the chords 
tendinese. These changes are generally secondary to 
endocarditis. 

The earliest change of endocarditis is usually the pro- 
duction of vegetations on the auricular surface of the 
valve, which, while causing no obstruction, render the 



DISEASES OF THE HEART. 335 

surface rough and allow of the production of a murmur. 
Secondary thickening of the leaflets and the chordae 
tendineae prevent free motion of the valves, causing them 
to project into the center of the ventricle, and, while the 
obstruction is slight, fluid veins are formed. Attach- 
ment of the edges of the leaflets may occur, converting 
the valve into a funnel, and producing more or less inter- 
ference with the flow of blood. This condition is 
especially liable to occur in children. More marked 
adhesion and retraction of the valves may occur, so that 
the opening becomes a mere split. 

Effect of Mitral Obstruction.- — The changes that occur 
as the result of mitral stenosis are comparatively slow, 
and the effects produced upon the circulatory system can 
be divided into three stages. 

First Stage. — The immediate effect of obstruction at 
the mitral orifice is to increase the work of the left 
auricle, which is met by a compensating hypertrophy. 

When the obstruction to the flow of blood is slight, 
the effect may not extend beyond a simple hypertrophy 
of the left auricle, which is sufficient to force the normal 
amount of blood into the ventricle and to prevent any 
interference with the pulmonary circulation. 

Second Stage. — When the obstruction is more 
marked the effect may extend beyond the left auricle 
and involve the pulmonary circulation and the right 
heart. Interference with the pulmonary circulation 
may occur in two ways, according as the hypertrophy of 
the left auricle is sufficient or insufficient to compensate 
for the obstruction. (1) Hypertrophy of the left auricle 
may be sufficient to close the openings of the pulmonary 
veins and to empty itself at the time of auricular systole, 
and yet pressure in the pulmonary circulation may be 
above normal. This occurs when the obstruction at the 
mitral orifice is so marked that the aspirating force of 
the heart and the pressure in the pulmonary veins are 
insufficient to empty the pulmonary circulation during 
the early portion of diastole. This increases pressure 



336 THE CIRCULATORY SYSTEM. 

in the pulmonary veins, arteries and capillaries, causing 
secondary hypertrophy of the right ventricle, with 
accentuation of the pulmonic second sound. Dilatation 
of the left auricle is not present during this period of the 
second stage, and only occurs when the power becomes 
insufficient to overcome obstruction. 

(2) When the hypertrophy of the left auricle is 
unable to overcome the obstruction, dilatation occurs, 
and with auricular systole the blood is forced from the 
auricle, not only through the obstruction, but also into 
the pulmonary veins, and marked congestion of the lung 
ensues. As was explained under "Mitral Regurgita- 
tion," this interference with pulmonary circulation is 
compensated for by hypertrophy of the right heart. 

During this stage the left ventricle may be normal, 
or, on account of imperfect distension of its cavity dur- 
ing diastole, this cavity may be reduced in size. 

Third Stage. — Failure of right ventricular compensa- 
tion occurs in mitral obstruction under the same condi- 
tions and with the same effects as has already been 
noted under "Mitral Regurgitation." 

Physical Signs. Inspection. — The changes noted by 
inspection correspond to change in the position of the 
j apex beat and the condition of the circulation. 

In the first stage, there being no increase in the size 
of the ventricles, the apex beat is in the normal position. 
In children the pulsation of the auricle may be noted in 
the second and third left interspaces. 

In the second stage, especially during the early period, 
the apex beat is displaced upward and to the left, even 
beyond the nipple line. (Fig- 79.) With dilatation of 
the right ventricle there is increase in the area of 
visible apex beat and extension toward the median line. 
When the disease occurs in early life there may be slight 
enlargement of the prsecordia. 

In the third stage the apex beat is diffused and indis- 
tinct. Interference with the pulmonary circulation 
causes marked cyanosis of the membranes and a dusky 



DISEASES OF THE HEART. 337 

appearance of the skin. Interference with return cir- 
culation causes the veins of the neck to become promi- 
nent, and pulsations are noted when tricuspid regurgita- 
tion is present. 

Palpatiox. First Stage. — The apex beat may be 
normal or slightly decreased in force. Over the apex 
beat a thrill may be felt. The characteristic feature of 
the thrill is its sudden termination at the moment that 

Fig. 79. 




Displacement of apex upward and to the left in mitral stenosis. 

the apex beat is felt. The duration of the thrill and its 
length will depend upon the degree of obstruction and 
the force of the current during different periods of ven- 
tricular diastole. 

The pulse may be normal or show slight emptiness of 
the artery. 

Second Stage. — Hypertrophy of the right ventricle 
causes the apex beat to be more diffused. Over the left 
intercostal spaces the closure of the pulmonary valves 
22 



338 THE CIRCULATORY SYSTEM. 

may be felt as a shock. The thrill is more marked. The 
pulse may be normal and regular when patient is quiet, 
becoming irregular on exertion. 

Third Stage. — With failure of right-side compensa- 
tion the apex beat becomes more diffused and wave-like, 
the thrill weaker or absent, or, if present, is felt but for 
a short time before the apex beat. The pulse is small, 
irregular, and the arteries are imperfectly filled. 

When failure of compensation has occurred gradually 
with long-continued interference with the venous circu- 
lation, increased pressure in the arteries, due to obstruc- 
tion to capillary circulation may cause hypertrophy of 
the left ventricle, so that the apex beat will be more 
marked than during the earlier stages. 

Percussion. First Stage. — The area of percussion 
dullness is normal. During the second and third stages 
it corresponds to the anatomical enlargement of the 
heart. (See Mitral Regurgitation. ) 

Auscultation. — The diagnostic sign of obstruction 
at the mitral orifice is the presence of a marked vibra- 
tory murmur, which begins an appreciable time after 
the second sound and increases in intensity until ter- 
minated abruptly by the accentuated first sound (pre- 
systolic) ; the point of maximum intensity is at the apex, 
around which it is diffused. 

The above are characteristics of the typical murmur 
of mitral obstruction, but it is subject to variations in 
quality, duration and intensity, dependent upon the 
degree and character of the obstruction and the force 
of the current of blood through the opening. 

The murmur has been described as rough, rumbling, 
rolling, churning, grinding, blubbering, and may be 
simulated by pronouncing the syllables "rrb," "rrt." 

The most distinctive feature is the short, sharp sound 
that terminates the murmur, which always persists, 
even though the other phases of the murmur are absent. 
It may be the only sign present of mitral obstruction, 
as the murmur is not constant. 



DISEASES OF THE HEART. 



339 



The production of a murmur demands that the blood 
pass through the contracted orifice with a definite 
amount of force. As the rapidity of the passage of the 
blood through the heart varies from time to time, accord- 



Fig. 80. 




Congenital mitral stenosis (rhachitic thorax). 
X Ray tracing of outline of the heart. 

nig to the rate of cardiac action, the murmur may be 
absent at one time and present at another. Variations 
m the force of the current also cause a rise and fall in 
the intensity of the murmur. 



340 



THE CIRCULATORY SYSTEM. 



The duration of the murmur and its relation to the 
first and second sounds of the heart also vary. When 
the murmur is heard only for a brief period, just before 
the first sound, it is distinctly pre-systolic. The dura- 
tion may be longer, however, so that it occupies the 
major portion of diastole, or in some cases it may be 
heard with greatest intensity almost immediately after 
the occurrence of the second sound; but this murmur 
can never occur with or replace the second sound of the 

heart. (Fig. 61.) 

The presence of a murmur during the different por- 
tions of diastole depends upon the nature of the force. 
When the force necessary to produce the murmur is due 
to auricular systole, the murmur is heard just before 
the first sound. When the constriction is marked and 



Fig. 81. 




Double crescendo. Mitral obstructive murmur. 

the force is supplied by the aspirating action of the 
left ventricle and the tension that exists at the time m 
the auricle and pulmonary veins, the murmur will occur 
earlier in diastole. 

First Stage.— The murmur is harsh m proportion to 
the constriction and the auricular hypertrophy, mark- 
edly pre-systolic, and terminated with the accentuated 
first sound of the heart, which is clear. In slight steno- 
sis the accentuated first, sound may only be present, or 
the murmur may be temporarily absent when the patient 
is in bed and the cardiac action is quiet. 

Second Stage.-— The murmur is harsh, occurs earlier 
in the diastole, with marked pre-systolic increase m in- 
tensity. The pulmonic second sound is accentuated, 
and there is a tendency to reduplication of the second 
sound over the base of the heart and absence of the 



DISEASES OF THE HEART. 



341 



second sound at the apex. Change in the second sound 
at the base or apex is due to increased pressure in the 
pulmonary artery, with diminished tension in the aorta. 
During this stage, when the power of the left auricle 
is failing, two points of intensity may be noted (double 
crescendo) ; one mid-diastolic, and the other pre-systolic, 
depending upon the varying force of the blood current. 
(Fig. 81.) Auscultation of the lung during the early 

Fig. 82. 




Mitral stenosis. 
X-Ray tracing of outline of the heart 



portion of this type shows a slight harshness of the 
respiratory murmur. Long-continued high tension in 
the pulmonary circulation later produces signs of 
cardiac pneumonia— brown induration. 

Third Stage. — In proportion to the feebleness of the 
left auricular systole and lowering of the pressure in 
the pulmonary circulation, due to failure of right heart 
compensation, the murmur loses its characteristic rough- 



342 THE CIRCULATORY SYSTEM. 

ness or disappears. Accentuation of the second sound 
is absent. The first sound becomes short, sharp and 
sudden ; over the tricuspid area the soft systolic murmur 
of tricuspid regurgitation may be detected. Over the 
lungs, failure of the right heart is shown by the physical 
signs of pulmonary oedema and effusion into the serous 
cavities, as noted under "Mitral Regurgitation." 

Differential Diagnosis. — Murmurs that may be mis- 
taken for that of mitral stenosis are (1) those whose 
points of maximum intensity are at the apex — mitral 
regurgitation, tricuspid regurgitation — and (2) those 
that occur during diastole — aortic regurgitation (Flint 
murmur), tricuspid stenosis, pericardial (friction) 
murmurs. 

Mitral Regurgitation. — The murmur of mitral 
stenosis increases in intensity up to the occurrence of 
the first sound of the heart ; that of mitral regurgitation 
begins with the first sound, and gradually diminishes in 
intensity. 

The murmur of mitral stenosis is localized at the site 
of the visible apex beat ; that of mitral regurgitation is 
transmitted beyond the prsecordia toward the axilla, and 
is heard also behind. 

Mitral regurgitation and mitral stenosis are fre- 
quently associated. _ Under these circumstances, when 
both murmurs are present, a harsh, rough murmur is 
heard, culminating with the sharp first sound, which is 
immediately followed by a softer, blowing murmur, 
which is transmitted toward the axilla. 

Tricuspid Regurgitation. — The murmur of tri- 
cuspid regurgitation may be heard with the point of 
maximum intensity just within the apex beat. When 
not secondary to mitral stenosis, its time, its area of 
diffusion and the secondary effects upon the venous cir- 
culation are the distinctive features. When associated 
with mitral stenosis it follows the first sound of the 
heart, and is soft, blowing in character. Tricuspid 
regurgitation is determined more by the changes in the 
venous circulation than by the presence of the murmur. 



DISEASES OF TBE HEART. 343 

Aortic Regurgitation. — The murmur of mitral 
stenosis may occupy most of the diastolic period. It 
usually begins an appreciable time after the occurrence 
of the second sound, and can never accompany or re- 
place it. The murmur of aortic regurgitation, on the 
other hand, accompanies, replaces or follows immedi- 
ately after the aortic sounds. 

The murmur of mitral stenosis is suddenly termi- 
nated with the occurrence of the first sound. That of 
aortic regurgitation is most marked at the beginning of 
diastole, and usually fades out before the occurrence of 
the first sound. 

"Flint" Murmur. — This may occur as a marked 
presystolic increase of the diastolic murmur, or may 
occur as a separate sound in aortic regurgitation. 

Tricuspid Stenosis. — The time of these two mur- 
murs are identical. Their points of maximum intensity 
may be slightly separated, but usually they are the same. 
The murmurs are also similar in quality and duration 
during the diastolic period. The differentiation is 
extremely difficult, and is made only when the two 
murmurs vary in point of maximum intensity and in 
quality. 

Pericardial Friction Sounds. — Pericardial fric- 
tion sounds, especially when due to adherent pericar- 
dium, may simulate the murmur of mitral stenosis, but 
the sound does not terminate with the apex beat, being 
carried slightly into the systolic period. 

OBSTRUCTION AT THE AORTIC ORIFICE. 
AORTIC STENOSIS. 

Obstruction to the flow of blood through the aortic 
orifice, due to diminution of its calibre, is a relatively 
rare condition, but signs somewhat similar to those pro- 
duced by narrowing of the orifice are present when the 
orifice remains of the same diameter as in health. 



344 THE CIRCULATORY SYSTEM. 

True obstruction, or stenosis, at the aortic orifice may 
be caused by (1) contraction of the fibrous ring; (2) 
rigidity of the cusps of the valves ; (3) adhesions of the 
borders of the valves, and (4) masses of vegetations. 

Non-obstructive conditions producing a murmur at 
the aortic orifice may be (1) roughening of the surface 
of the valves by vegetations, calcareous deposits; (2) 
changes in the size of the aorta (relative obstruction), 
and (3) changes in the specific gravity of the blood 
(haemic or functional murmur). 

Effect of Stenosis. — The effects of obstruction at the 
aortic orifice may be divided into three stages, according 
as they are limited to (1) the left ventricle, (2) extend 
beyond the mitral valve and involve the pulmonary cir- 
culation and right ventricle, (3) when they extend 
beyond the tricuspid valve and involve the venous 
circulation. 

First Stage. — As the lesions that produce obstruction, 
whether due to endocarditis or secondary changes in the 
aorta, progress slowly, there is a corresponding gradual 
increase in the work of the left ventricle, which is met 
by compensating hypertrophy without any correspond- 
ing degree of dilatation. Dilatation does not occur 
until the left ventricle fails to empty its cavity at each 
systole. This failure may be temporary, as when the 
cardiac rate is suddenly increased. Compensation by 
increased hypertrophy may again occur, but the dilata- 
tion of the cavity generally remains. 

The effect of the stenosis is limited to the left ven- 
tricle for a variable period until repeated, or extensive 
dilatation of the left ventricular cavity causes imperfect 
action of the papillary muscles and enlargement also 
of the auriculo- ventricular ring and relative insuffi- 
ciency of the mitral valves. The effect upon the arterial 
system is marked, producing a characteristic pulse. 

Second Stage. — When regurgitation at the mitral 
orifice occurs the work of the left ventricle is tem- 
porarily relieved, and there is immediate interference 



DISEASES OF THE HEART. 345 

with the pulmonary circulation, increased tension in the 
pulmonary artery and compensating hvnertrophy of the 
right ventricle. For subsequent changes in this stage, 
and those that occur during the third stage, with failure 
of compensation by the right ventricle, see Mitral Ke- 
gurgitation, page 323. 

In conditions which give a similar murmur, but are 
non-obstructive, the primary effect on the left ventricle 
and the subsequent changes in the heart are absent. An 
exception to this is where atheroma or less of elasticity 
of the aorta has preceded the dilatation of the aorta, 
when there is hypertrophy of the left ventricle. In this 
condition dilatation of the aorta may occur, instead of 
regurgitation, at the mitral orifice. 

Physical Signs. Ixspectiox. — The position and 
extent of the apex beat correspond to the changes in the 
size of the heart. 

First Stage. — When there is hypertrophy only of the 
left ventricle, the apex beat may be in the normal posi- 
tion, or, at most, carried slightly to the left, and is well 
defined. When hypertrophy and dilatation are asso- 
ciated, it is displaced to the left and downward, and the 
area is more diffused. 

Second Stage. — The apex beat is seen further to the 
left, and also over the lower portion of the praecordia. 
Visible pulsations may be present in the third, fourth 
and fifth interspaces (left), and there may be precor- 
dial bulging. 

Third Stage. — Dilatation of the right ventricle, ve- 
nous engorgement, and tricuspid regurgitation give a 
diffused, wavy pulsation, with enlargement and pulsa- 
tions of the veins in the neck. 

Palpatiox. First Stage. — Palpation gives impor- 
tant information concerning not only the condition of 
the heart, but also the degree of stenosis and the nature 
of the structural changes. The apex beat is character- 
istic. It lacks the sudden, sharp tap of the normal 
heart, and the impulse is slow, labored and sustained, 



346 THE CIRCULATORY SYSTEM. 

terminating with a short, sharp recoil that may give the 
sensation of a slight tap. 

When dilatation is added to hypertrophy, the labored 
and forcing action of the heart is increased, but it does 
not have the lifting, heaving impulse of hypertrophy 
and dilatation due to other causes. Over the base of the 
heart an intense thrill may be felt; the point of maxi- 
mum intensity is usually in the aortic area, but it may 
be detected also at the apex. 

The intensity of the thrill does not indicate the degree 
or nature of the lesion, although it occurs most fre- 
quently when the obstruction is due to fibrous or athe- 
romatous thickening of the aortic ring or cusps. The 
intensity of the thrill is more directly connected with the 
force of the current. 

The pulse is of great importance in aortic stenosis. 
Its character, when taken in connection with the changes 
in size of the heart, determines the extent of the lesions 
that cause the svstolic murmur at the aortic orifice. 

In proportion to the degree of obstruction is the vari- 
ance between the slow, labored, but forcible apex beat 
and the small pulse wave. 

Normally, with ventricular systole the blood is rapidly 
forced into the aorta, which is distended, giving to the 
radial artery the characteristic pulse wave. In propor- 
tion to the obstruction the blood is slowly forced into 
the aorta during the entire period of systole, so that 
there does not occur the sudden distension of the aorta, 
and the pulse wave lacks the sharp rise and continues 
longer. 

Non-obstructive conditions, producing aortic systolic 
murmurs, do not give this type of pulse. 

The characteristics of the pulse in aortic stenosis are 
well seen in the sphygmographic tracings (Fig. 52). 

The effect of exertion on the pulse is important in 
determining the power of the hypertrophied left ven- 
tricle to compensate for the lesion. When exertion in- 
creases the frequency and force of the pulse, then com- 



DISEASES OF THE HEART. 347 

pensation is perfect, be the obstruction small or great. 
If it causes a long, even and regular pulse while the 
patient is quiet, to become shorter, small and irregular 
in force and rhythm, then the compensation is sufficient 
when the heart is beating slowly,, but is inadequate to 
empty the ventricle when the rate is increased. 

Second Stage. — When regurgitation at the mitral 
orifice occurs, the cardiac impulse is less labored, but 
shorter and more diffused. The thrill over the base of 
the heart becomes less intense or may disappear, and the 
pulse becomes shorter and smaller and is not disturbed 
to the same extent by exertion. 

Third Stage. — The impulse becomes indistinct and 
wavy, the thrill is absent and the pulse is small and 
thready. 

Peecussion. — Changes in the areas of cardiac flat- 
ness and relative dullness correspond to the changes in 
the size of the right and left ventricles. During the 
stage of simple hypertrophy of the left ventricle, no 
change in the percussion can be detected. With the 
occurrence of dilatation, the area of deep dullness is 
enlarged to the left and downward. 

Auscultation. — The characteristic sisri of aortic 
stenosis is a systolic murmur, occurring at the base 1 
with the first sound of the heart, with the point of maxi- 
mum intensity in the second right intercostal space and 
transmitted upward and laterally. A marked feature 
of svstolic murmurs made at the aortic orifice is their 
transmission into the great arteries. (Fig. 66.) The 
murmur varies in quality, duration, point of maximum 
intensity and area of diffusion, according to the char- 
acter and extent of the lesion and the secondary changes 
in the heart. 

First Stage. — When the obstruction is slight and due 
to vegetations or recent endocarditis, the murmur is soft, 
and occupies but a portion of the systolic period. The 

1 If the murmur is timed by the apex beat or the first sound at the 
apex, it may seem to occur slightly after the beginning of systole. 



348 THE CIRCULATORY SYSTEM. 

point of maximum intensity is at the second right inter- 
costal space, and the area of diffusion is but slightly 
beyond it. The aortic second sound is only slightly 
diminished. 

When fibrous or atheromatous changes have stiffened 
the valves and the aortic ring, the murmur replaces the 
first sound at the base, and is harsh and sawing in char- 
acter, especially if thrill be present. It may persist 
during the entire systolic period. The second sound is 
muffled or impure ; the point of maximum intensity is at 
or above the second right costal cartilage, and the mur- 
mur is heard over the upper portion of the sternum, 
laterally along the ribs and clavicles, and may be heard 
in the interscapular space behind. 

When dilatation of the left ventricle occurs, the point 
of maximum intensity is at the left edge of the sternum, 
at the junction of the third and fourth costal cartilages. 
A systolic murmur may also be heard at the apex, which 
may be due to conduction of the murmur made at the 
base through the ventricular wall, but usually caused by 
slight regurgitation at the mitral orifice. When due to 
mitral regurgitation, at first the murmur may be only 
present after exertion or other causes that increase the 
cardiac rate. 

Second Stage. — The murmur at the base loses its 
harshness. Its area of diffusion is less, and the murmur 
at the apex becomes more marked ; it is associated with 
accentuation of the pulmonic second sound and with 
other signs of pulmonic congestion, and later with those 
of the third stage — venous congestion and tricuspid 
regurgitation. (See Mitral Eegurgitation. ) 

Diagnosis of the Pathological Condition. — The diagnosis 
of aortic stenosis from other conditions causing a sys- 
tolic murmur over the aortic area is made by the asso- 
ciation with the murmur (a) the signs of primary 
cardiac hypertrophy of the left ventricle, (o) the 
presence of a thrill, (c) the characteristic contrast be- 
tween the force of the apex beat and the size of the pulse. 



DISEASES OF THE HEART. 



349 



Aortic obstruction rarely continues as an isolated 
lesion for any length of time, being usually associated 
with regurgitation. In uncomplicated stenosis the aortic 
second sound is impure, muffled and lacks the normal 
tense, valvular element. When regurgitation occurs the 
aortic sound becomes very feeble, or is replaced by the 
murmur. 

Roughening of the surface of the valves gives a soft 
systolic murmur, which is localized around a point of 

Fig. 83. 




Aortic obstruction and dilatation of aorta. 



maximum intensity at the second left intercostal space ; 
the aortic second sound is clear, and there is no change 
in the position and force of the apex beat or in the pulse. 
These sounds are identical with the early stage of acute 
endocarditis at the aortic valve, that may ultimately 
produce true obstruction. 

Dilatation of the aorta, altering the correlation be- 
tween the size of the aortic orifice and the cavity beyond, 



350 THE CIRCULATORY SYSTEM. 

frequently causes a murmur. The early changes due to 
atheroma diminish the elasticity of the aorta, converting 
it into a rigid tube, increasing the work of the heart, and 
causing hypertrophy of the left ventricle. If the aortic 
surfaces are also roughened a harsh murmur will be 
present, the aortic second sound will be accentuated, and 
there will be more marked distension and pulsation of 
the vessels of the neck as a result of the loss of distensi- 
bility in the aorta. (Fig. 83.) The pulse wave will be 
more sudden, and correspond in size and force to 
the apex beat. When dilatation occurs the murmur 
becomes softer than that of simple aortic stenosis, 
the second sound is accentuated, the apex beat has 
the prolonged, labored character, and the pulse is 
sudden and short. In dilatation and relaxation of 
the aorta, due to neuro-cardiac conditions (Grave's 
disease, hysteria, etc.), the murmur is soft, blowing 
in quality and heard over the vessels of the neck ; 
the cardiac action is rapid ; the first sound of the 
heart is short and sharp; the second sound is clear; the 
pulse full and compressible, and there are pulsations in 
the vessels of the neck. 

Differential Diagnosis. Aneurism. — Aneurism of the 
ascending aorta may give a systolic murmur and thrill 
similar to those in aortic stenosis, but the second sound 
is increased in intensity, and may be felt as diastolic 
valve shock. There is diminution of the resonance over 
the upper portion of the sternum, and there is generally 
present pulsation over the upper portion of the sternum, 
and pressure symptoms involving the bronchi and nerves. 
The pulse does not show the characteristics of aortic 
stenosis. 

HiEMic murmurs having their point of maximum 
intensity at the second right intercostal space are heard 
also in the second left intercostal space, the usual site of 
maximum intensity. They are soft, blowing murmurs, 
and are not associated with signs of cardiac hyper- 
trophy. The pulse is short, soft and compressible. The 



DISEASES OF THE HEART. 351 

skin and mucous membranes have the characteristic ap- 
pearance of ansemia. 

Pulmonary obstruction has a systolic murmur, 
with its point of maximum intensity to the left of the 
sternum, but the murmur is not transmitted into the 
vessels of the neck. The aortic second sound and pulse 
are unchanged. 

Patent ductus arteriosus gives a systolic mur- 
mur, with the point of maximum intensity in the second 
left intercostal space. The murmur begins somewhat 
after the first sound (late systolic), and continues 
usually after the second sound. It may be heard over 
the entire upper portion of the chest, but is "never car 
ricd into the vessels of the neck or arms." 

REGURGITATION AT THE AORTIC ORIFICE. 

Regurgitation at the aortic orifice is always dependent 
upon structural changes in the valves guarding it, or 
upon dilation of the fibrous ring. Perfect closure at this 
orifice is dependent upon normal elasticity of the semi- 
lunar valves, whose free edges are forced together by 
the pressure of the blood in the aorta at the time of 
diastole. 

Regurgitation may be caused by (1) vegetations on 
the free surface of the valves, preventing perfect coapta- 
tion; (2) loss of tissue due to ulcerative endocarditis; 
(3) the cusps may be thickened, shrunken or deformed 
by sclerotic processes, due to chronic endocarditis or 
secondary to changes in the aorta. 

The sclerotic processes that produce thickening and 
distortion of the cusps or changes in the aorta, are slow, 
but progressive, so that there is a tendency for the in- 
sufficiency of the valve to gradually increase. 

(4) Dilatation of the aorta may be so marked as to 
involve the fibrous ring and produce enlargement of the 



352 TEE CIRCULATORY SYSTEM. 

aortic orifice, rendering it too wide to be closed by the 
cusps 1 (relative valvular insufficiency ) . 

(5) Kupture of the aortic cusps may be caused by 
violent muscular exercise. It is doubtful whether rup- 
ture of a cusp can occur from this cause unless it has 
been previously diseased. 

Effects of Regurgitation at the Aortic Orifice. — The 
effects of regurgitation at the aortic orifice can be 
divided into three stages, according as they are limited 
(1) to the left ventricle and arterial system; (2) as they 
extend beyond the mitral valve and involve the pul- 
monary circulation and right ventricle, and (3) as they 
extend beyond the tricuspid valve and cause interference 
with the general venous system. 

First Stage. — The immediate effect is exerted during 
diastole on the left ventricle and arterial circulation. 
On the ventricle the effect of the regurgitant stream is 
to produce dilatation. The dilating force is due (a) to 
the pressure of the regurgitant current from the aorta, 
and (b) to that in the auricle and pulmonary veins, 
reinforced by auricular systole. The blood is driven 
into the ventricle by the elastic recoil of the aorta, and is 
aspirated also into the ventricle during the early portion 
of diastole by the expanding cavity. When the ventricle 
is filled, the pressure in the aorta continues to act on the 
left ventricle through the incompetent valve according to 
Pascal's law, and cause still further dilatation. The 
rapid filling of the ventricle from the aorta removes one 
of the normal forces that aids the flow of blood from the 
auricle (see Mitral Obstruction, page 324), so that with 
auricular systole a larger amount of blood is forced into 
the already overfilled ventricle. 

On the aorta an equally marked effect is produced 
during diastole, . according to the extent of the regurgita- 
tion. There is a sudden diminution of the blood 



i Dilatation of the fibrous ring sufficient to cause incompetency of 
the valve has been denied, but its occurrence must be admitted. 



DISEASES OF THE HEART. 353 

pressure, which is felt throughout the entire arterial 
svstem. 

The primary effects produced during diastole are fol- 
lowed hj secondary changes in the ventricle and aorta 
during systole. The increased amount of blood in the 
ventricle augments the work of the heart during systole, 
which is met by a compensating hypertrophy. The 
greater capacity of the ventricle causes a larger amount 
of blood than normal to be driven into the aorta, and the 
hypertrophied muscle propels it with greater force. 
These two factors cause increase in the normal blood 
pressure and overdistension of the aorta and great ves- 
sels during systole, which is followed by almost as 
sudden a fall of blood pressure during diastole, due to 
aspiration into the ventricle. 

The effect of the sudden forcing of an increased 
amount of blood into the arteries causes them to become 
not only dilated, but also elongated and tortuous. The 
effect upon the arteries may extend to the veins and 
capillaries. 

The dilatation of the ventricle during diastole, and 
the hypertrophy of the ventricle and dilatation of the 
aorta during systole must be considered as correlated 
effects of aortic regurgitation. In uncomplicated re- 
gurgitation they bear a definite relation to each other. 
As the dilating force is constantly acting on the ven-^ 
tricle, there may be frequent attacks of dilatation, fol- 
lowed by recompensation, before insufficiency at mitral 
valve occurs. Under these circumstances the left ven- 
tricle may attain enormous proportions (cor bovinum). 

When obstruction is associated with regurgitation, 
the sequence of effects is disturbed. Hypertrophy of 
the left ventricle is most marked, while dilatation of 
the aorta is less, due to the slowness with which the 
enlarged ventricle empties itself through the constricted 
opening. 

Second Stage. — TVlien the mitral valve becomes 
incompetent through dilatation of the ventricle or 
23 



354: THE CIRCULATORY SYSTEM. 

changes in the cn&ps of the valves, there is marked inter- 
ference with pulmonary circulation and the functions 
of the right heart, causing the consecutive changes, as 
described in Mitral Regurgitation (page 325). 

Incompetency of the mitral valve secondary to aortic 
regurgitation must not be considered as an unfavorable 
complication. Generally it is a conservative process, re- 
lieving the stress on the left ventricle. When com- 
pensating hypertrophy does not keep pace with dilata- 
tion through imperfect nutrition, or is ruptured by in- 
tercurrent causes, as physical exertion, disease, etc., the 
constantly acting dilating force tends to overpower the 
contracting power of the ventricle, and death from 
asystole occurs unless regurgitation through the mitral 
orifice takes place, relieving the left ventricle both dur- 
ing diastole and systole. 

Compensation for the aortic regurgitation by hyper- 
trophy of the right ventricle may exist for a long time. 
When it fails (third stage), it is due to the same cause 
that induces it in lesions at the mitral orifice. 

Physical Signs. Inspection. — Inspection of the prse- 
cordia and arteries gives important information, and is 
• frequently sufficient for diagnosis. 

First Stage. — When the regurgitation has produced 
but a small amount of dilatation and hypertrophy, the 
apex beat is but slightly displaced, and is localized. As 
the size and power of the heart increase, the apex is car- 
ried further downward aud outward, and the visible 
impulse becomes more marked, with a diffused heaving 
of the chest and bulging of the prsecordia. In some 
cases the diminution of the size of the enlarged heart 
during systole and the increased negative pressure in the 
thorax are sufficient to cause retraction of the chest wall 
over the region of the apex beat, instead of the usual lift- 
ing impulse. 

Pulsations of the aorta, carotids, subclavian^, 
brachials and more peripheral arteries are present in 
proportion to the extent of the lesion. The blood-vessels 



DISEASES OF THE HEART. 355 

also stand out more prominently, and when they are 
markedly tortuous the pulsations in the more superficial 
ones have a peculiar vermicular appearance. Pulsation 
in the vessels may be strong enough to produce move- 
ment of the extremities, or even of the head. In well- 
marked cases capillary pulsation may be present. 

Second Stage. — The apex boat becomes more diffused, 
and is carried further to the left and downward. The 
pulsations in the vessels of the neck are not as marked. 

Third Stage. — -The heaving left impulse is replaced 
by a diffuse apex beat, extending to the epigastrium. 
Systolic pulsations are seen in the jugulars. 

Palpation. — Palpation of the pra?cordia shows the 
apex beat to be changed in position and character, ac- 
cording to the relative degree of dilatation and hypertro- 
phy of the left ventricle, and subsequently of the right 
ventricle. 

First Stage. — In hypertrophy with slight dilatation 
(eccentric hypertrophy), the apex beat is displaced 
slightly to the left. The force is increased. In well- 
marked hypertrophy and dilatation the systolic impulse 
is lifting and heaving in character, and may jar the 
entire thorax and give a well-marked thrust if the ribs 
are elastic. Diastolic recoil may be detected, especially 
in cases where there is systolic retraction of the chest 
wall. When dilatation exceeds hypertrophy, the apex 
beat is diffused and lacks force. Diastolic thrill may be 
felt over the base of the heart or diffused over the entire 
prsecordia. The pulse of aortic regurgitation is the most 
diagnostic of all the valvular diseases, and is also impor- 
tant in estimating the degree of the lesion. The char- 
acteristic feature of the pulse depends on the sudden 
emptying and collapse of the artery during diastole, 
followed by an equally sudden overfilling during systole, 
so that the highest and lowest points of tension follow 
each other very rapidly. The sphygmographic tracings 
(Fig. 42) show this. The passage of the pulse wave 
under the finger causes a sensation as of the passing of a 



356 THE CIRCULATORY SYSTEM. 

series of hard particles, and the pulse is described as 
shotty or water-hammer (Corrigan's pulse). Elevating 
the arm intensifies this characteristic by favoring, 
through gravity, the emptying of the artery during 

diastole. 

The pulse is regular as long as hypertrophy compen- 
sates for the regurgitation. When it becomes unequal 
to this task, irregularity, both in rhythm and force, 
occurs. When the regurgitant stream is small, the 
water-hammer character of the pulse is not marked. It 
becomes progressively more prominent with increase in 
dilatation of the left ventricle, and it is also exaggerated 
when regurgitation is associated with anaemia or any 
condition favoring low resistance in the arteries and 
capillaries. Obstruction at the aortic orifice by inter- 
fering with the rapid emptying of the ventricle causes 
the pulse to be smaller and longer. 

Second Stage. — With regurgitation at the mitral valve 
and hypertrophy of the right ventricle, the apex of the 
left ventricle is displaced from the chest wall. The 
impulse is carried downward, and also toward the 
median line, and may be felt in the epigastrium. 

When regurgitation at the mitral valve takes place, 
the pulse becomes smaller; with the third stage (failure 
of compensation) feeble and irregular. 

Third Stage. — Failure of compensation and dilatation 
of the right ventricle cause a feeble, wavy, diffused im- 
pulse, which is also irregular in force and rhythm. 

Percussion. — The increase in the area of percussion 
dullness corresponds to the changes in the size and shape 
of the heart. First Stage. — When dilatation is slight 
and hypertrophy well marked, the area of dullness over 
the apex is sharply triangular, and extends downward 
and outward. Increase in dilatation causes the apex 
area to become rounded and extend further toward the 
left. There is no change along the left border of the 
sternum until, second stage, right ventricular hyper- 
trophy occurs. Third Stage.— Dilatation of the right 



DISEASES OF THE HEART. 357 

ventricle may cause dullness to be detected to the right 
of the sternum. Dilatation of the aorta may cause in- 
creased dullness at the level of the second interspace to 
the right of the sternum. 

Auscultation. — The murmur distinctive of regurgi- 
tation at the aortic orifice is diastolic, with the point of 
maximum intensity over the sternum or at the left edge 
opposite the third interspace and fourth costal cartilage, 
transmitted down the sternum to the ensiform cartilage, 
and at times to the apex. It is also heard over the aorta 
and arteries. (Fig. 67.) 

The murmur varies in quality and loudness, point of 
maximum intensity, area of diffusion, and duration, 
according to the character and extent of the lesion at the 
aortic orifice and the secondary changes in the aorta and 
heart. 

The quality and loudness of the murmur are de- 
pendent upon the nature of the opening through which 
the blood regurgitates (whether large or small, rough or 
smooth), and the force of the blood current determined 
by the blood pressure in the aorta. 

First Stage. — The murmur may be soft, blowing in 
character, and scarcely audible. When the regurgitant 
stream is forced through a narrow, rough opening with 
great force, the murmur is harsh, grating, sawing and 
audible at times some distance from the patient. When 
the opening is large the murmur is more gushing, and 
rapidly diminishes in loudness. When a murmur that 
has been loud becomes weaker and shorter, it indicates 
low pressure in the aorta, due to failure of cardiac 
power or decrease of resistance in capillaries. 

The duration of the murmur and its relation to the 
normal cardiac sounds are important data in determin- 
ing the nature and extent of the lesion. The longer the 
murmur persists during diastole, retaining the same 
degree of loudness, the smaller is the amount of blood 
that regurgitates through the valves and the slighter the 
effect on blood pressure in the aorta. Murmurs which 



358 



THE CIRCULATORY SYSTEM. 



are heard for a short time only during the early portion 
of diastole, and rapidly diminish in loudness*, indicate 
free regurgitation. 

The murmur may accompany, follow or take the place 
of the aortic second sound, according to the condition of 
the valves. When the incompetency is due to vegeta- 

Fig. 84. 




Aortic regurgitation (first stage). 



tions or deformities limited to one cusp, or when all 
the cusps are involved, but their elasticity is not 
destroyed, the aortic second sound may persist, and the 
murmur will accompany or follow it. In such cases the 
regurgitation is generally small, although free regurgi- 
tation may occur with persistence of the second sound. 



DISEASES OF THE HEART. 359 

When incompetency of the cusps is secondary to 
arterial disease or dilatation of the aorta, an accentuated 
aortic second sound may persist with the murmur. 
When the second sound is absent or the murmur replaces 
it, regurgitation is usually free, and not associated with 
stenosis. 

The point of maximum intensity and the area of dif- 
fusion vary greatly. The murmur may be heard loudest 
in the aortic area, over the sternum, opposite the third 
interspace, at the ensiform cartilage, and at the apex, 
or it may be almost equally intense over the entire 

prsecordia. 

The point of maximum intensity is at the aortic area, 
and associated with persistence of the aortic second 
sound when regurgitation is secondary to thickening or 
atheroma of the aorta. 

Free regurgitation, with very little diastolic tension 
of the aortic cusps, causes the murmur to be heard 
loudest over the right ventricle at the ensiform cartilage 
(conduction through the ventricular septum) and at the 
apex (conduction by the regurgitant stream). 

Frequently the quality of the diastolic murmur heard 
at the apex differs from that over the sternum. The dif- 
ference is due to the routes by which the vibrations made 
at the valve reach the surface; over the apex by the 
regurgitant stream giving a soft, blowing sound; over 
the sternum by the dense tissue giving a harsher, 
higher-pitched sound. (Fig. 68.) 

Over the carotids and distal arteries, diastolic mur- 
mur is detected in proportion to the freedom of regurgi- 
tation. (Duroziez.) 

A diastolic murmur is heard in addition to the nor- 
mal systolic murmur (pressure murmur) when the 
stethoscope is firmly pressed on the artery. It never 
occurs except in free aortic regurgitation, and is de- 
pendent upon a strong reflex current toward the heart. 
In slight regurgitation it is absent. 

In addition to the diastolic murmur, a systolic mur- 



360 



THE CIRCULATORY SYSTEM. 



mur is usually heard in the aortic area and over the 
arteries in well-marked cases of aortic regurgitation. 
The systolic murmur may be due to true obstruction or 
to dilatation of the aorta (relative obstruction) , which 
occurs in a greater or less degree in aortic regurgitation. 
When true obstruction and regurgitation are com- 
bined at the aortic orifice, the systolic murmur is harsh, 
and carried into the vessels of the neck with diminished 

Fig. 85. 




Aortic regurgitation, with slight regurgitation at mitral 
(beginning second stage). 



intensity; but, in proportion to the obstruction, the 
carotid pulsations are less marked, and the pulse does 
not have the jerking, water-hammer character. 

When the systolic murmur is due to dilatation of the 
aorta, without diminution in the size of the aortic ori- 
fice, it is soft, blowing at the base of the heart, and holds 
its intensity over the vessels, or may become louder ; it is 
attended with marked pulsation in the carotids and the 
characteristic pulse. The diastolic murmur is relatively 



DISEASES OF THE HEART. 



361 



more intense than the systolic, and is especially intense 
over the carotids and distal arteries. The first sound of 
the heart is booming, and the pulmonic second sound is 
not accentuated. 

Second Stage. — When incompetency occurs suddenly 
at the mitral valve, due to muscular weakness, the 
diastolic murmur at the base becomes less intense ; the 

Fig. 86. 




Aortic stenosis and regurgitation with secondary mitral regurgitation. 



systolic murmur at the base becomes softer, and is not 
transmitted so far into the vessels of the neck. Over the 
apex another systolic murmur is heard, due to mitral 
regurgitation. It has all of the characteristics of that 
condition, and is associated with accentuation of the 
pulmonic second sound. After mitral regurgitation has 



362 THE CIRCULATORY SYSTEM. 

occurred, with temporary relief of the left ventricle, 
recompensation may occur, with persistence of the 
mitral murmur. Increased power of the heart is shown 
by the returning harshness and loudness of both diastolic 
and systolic murmurs over the base of the heart. 

Third Stage. — With failure of compensation by the 
right ventricle, the murmurs become indistinct or 
absent; there is a diminution of the pulmonic second 
sound, and the tricuspid regurgitant murmur and the 
physical signs of pulmonary congestion and oedema, 
already noted, supervene. 

OBSTRUCTION OF THE PULMONARY ORIFICE OR IN 
THE PULMONARY ARTERY. 

Obstruction of the pulmonary orifice occurring after 
birth is one of the rarest of lesions, although as a con- 
genital condition it is relatively frequent in proportion 
to the other cardiac defects, and is often associated with 
patent foramen ovale or other malformations of the 
heart. Although true obstruction is a most uncommon 
lesion, the diagnosis of obstruction at the pulmonary 
orifice is frequently made, as a number of conditions 
produce over the pulmonary valve area a systolic mur- 
mur whose points of maximum intensity and areas of 
diffusion are identical with those of stenosis. 

True obstruction at the pulmonary orifice may be due 
to changes in the cusps, as the presence of vegetations ; 
thickening and adhesion of their borders, producing 
a funnel-shaped opening; or the fibrous ring may be 
contracted. 

The pulmonary artery may be narrowed just beyond 
the orifice by endarteritis. Pressure along the course of 
the pulmonary artery by pleuritic adhesions and medias- 
tinal tumors (aneurisms, enlarged glands, malignant 
growths, etc.), may cause all the effects of obstruction at 
pulmonary orifice. 

Non-obstructive conditions causing a murmur over 



DISEASES OF THE HEART. 



363 



tlic pulmonic area are (1) anaemic conditions, especially 
chlorosis; (2) neuro-cardiac diseases, as. Grave's dis- 
ease and allied disorders; (3) altered relation of the 
heart to the chest wall, due to displacement and uncover- 
ing of the heart by retraction of the overlying lung, 
pleuritic changes, etc. 

Fig. 87. 




Pulmonary stenosis, tricuspid, regurgitation, pulsating liver. 



Effect of Obstruction at the Pulmonary Orifice. — Inter- 
ference with the flow of blood causes the right ventricle 
to become hypertrophied. If the obstruction is slight, 
no further effect may be produced. If the endocardial 
pressure is much increased during systole, regurgitation 
at the tricuspid valve occurs, causing both dilatation and 



364 



THE CIRCULATORY SYSTEM. 



hypertrophy of the right ventricle, interference with the 
general venous return and passive congestion of the 
abdominal organs, with oedema and effusion into the 
serous cavities. Clubbing of the fingers and toes, with 
enlargement and arching of the nails, occur in long- 
continued interference with return circulation. 

Physical Signs. Inspection. — Cyanosis is almost 
always present. If the obstruction is congenital it is 
most marked (blue baby) . When the obstruction occurs 



Fig. 88. 




Pulmonary stenosis (congenital). 



in early childhood or later in life, cyanosis may only be 
noticed on exertion. Over the prsecordia no change may 
be present unless there is dilatation and hypertrophy of 
the right ventricle, when the apex beat is carried down- 
ward, and is also seen in the epigastrium. With 
secondary tricuspid regurgitation, distension of the veins 
of the neck, and later pulsation in them, may be de- 
tected. The respiratory movements are increased, dysp- 
noea occurring on slight exertion. 



DISEASES OF THE HEART. 365 

Palpation. — Over the base of the heart there is felt 
a distinct systolic thrill, with the point of maximum 
intensity at the left edge of the sternum opposite the 
second and third interspaces, which may be diffused 
over a wider area. The apex beat is most marked over 
the site of the right ventricle. The pulse is not affected 
until failure of the right heart, with tricuspid insuffi- 
ciency. 

Percussion". — The area of cardiac flatness is slightly 
enlarged. When the dilatation of the right heart is 
marked, it may be detected to the right of the sternum. 

Auscultation. — The diagnostic sign is a harsh, 
superficial, systolic murmur, with the point of maxi- 
mum intensity at the junction of the second rib with the 
sternum. It may bo widely diffused over the upper 
portion of the chest, but is never heard in the great ves- 
sels of the neck. The second pulmonic sound is indis- 
tinct, or may be absent. The duration of the murmur 
is long, beginning sharply with systole and continuing 
almost to the second sound. The murmur is changed 
but slightly by the posture of the patient. Holding the 
breath causes it to become momentarily, more intense, 
and then weaker. Forced inspiration intensifies it; 
forced expiration weakens or annihilates it, (Fig. 
88.) 

Non-Obstructive Murmurs in the Pulmonic Area. — These 
have the same time (systolic) and point of maximum 
intensity as the obstruction. 

The ancemic murmurs are soft and blowing ; they are 
rarely musical or harsh. They are markedly influenced 
by position, being weaker in the upright and louder in 
the recumbent postures. They are influenced in the 
same manner as are the structural murmurs by respira- 
tion. They are associated with arterial murmurs in the 
carotids and subclavians, or with a venous hum. The 
patient is pale. On exertion a ruddy color may occur, 
out no cyanosis. There is no change in the size of the 
right heart, and they are not accompanied by thrill. 



366 THE CIRCULATORY SYSTEM. 

Frequently in women (for the first three days) after 
childbirth a murmur may be heard over the pulmonic 
area. It is apt to have a scratching, crepitant-like 
quality. (Figs. 72-73.) 

In the neuro-cardiac diseases the characteristics of 
the murmur are the same as those due to the anaemic. 
The cardiac action is increased, and there is marked 
pulsation in the vessels of the neck. 

Altered Relation of the Heart to the Chest Wall. — ■ 
Displacement of the heart by effusion into the pleural 
cavity frequently causes a murmur to be heard over the 
pulmonic area, which disappears on withdrawal of all 
or part of the fluid. Uncovering of the pulmonary 
artery by retraction of the lung also disturbs its relation, 
and causes a soft, blowing murmur to be present. These 
two conditions are associated with change in the pul- 
monary signs. Pleuritic adhesion, and retraction of 
the lung due to pleuritic or pulmonary changes, may 
cause slight narrowing of the pulmonary artery, as well 
as displacement. The murmur will be associated with 
depression of the thorax, with change in vocal fremitus, 
increased area of dullness opposite the fourth rib and 
signs of pulmonary and pleural changes. 

Differential Diagnosis. Systolic Murmurs. — Aortic sys- 
tolic murmurs usually have the point of maximum 
intensity to the right of the sternum, or may be localized 
in the pulmonary space. They are heard in the vessels 
of the neck. In aortic obstruction the pulse is small, 
and the cardiac change is limited during the earlier 
stages to hypertrophy of the left ventricle. 

Aneurismal Murmurs. — Aneurism may produce a 
systolic murmur and thrill in the pulmonic area, but it 
will be attended with pulsations and increased dullness 
over the upper part of the sternum and pressure 
symptoms. 

Patent Ductus Arteriosus. — The particular feature 
of the murmur of patent ductus arteriosus is its point of 
maximum intensity, which is further to the left of the 



DISEASES OF THE HEART. 367 

sternum, and also it continues beyond the second sound. 
As a congenital condition it is frequently associated with 
pulmonic obstruction. 

REGURGITATION AT THE PULMONIC ORIFICE. 

Pulmonic regurgitation due to structural changes at. 
the orifice is an extremely rare condition. When present, 
it is either congenital and associated with pulmonic 
obstruction, or, if acquired after birth, is due to 
ulcerative endocarditis or secondary to dilatation of the 
pulmonary artery. In the acquired form the cusps of 
the artery show pathological conditions analogous to 
those described under aortic regurgitation. 

Functional or physiological incompetency of the pul- 
monary valves may occur as a result of dilatation of the 
pulmonary artery, due to high blood pressure secondary 
to mitral disease, or changes in the lung interfering with 
the pulmonary circulation, as emphysema, fibrosis, etc. 
Physiological incompetency may take place under exces- 
sive functional activity of the respiratory organs, as in 
contests of speed, endurance, etc. When it occurs under 
these conditions, it protects the integrity of the pul- 
monary circulation. The physical signs of this type of 
regurgitation are slight, and usually masked by the 
rapidity of the cardiac action and exaggerated breath 
sounds. 

The Effect of Regurgitation at the Pulmonic Orifice.— 
The effect is to cause primary dilatation, with coinci- 
dent hypertrophy of the right ventricle, and later tri- 
cuspid regurgitation, with its accompanying phenomena. 

Physical Signs. Inspection. — The apex beat is car- 
ried to the left. Pulsations may be seen in the epigas- 
trium and in extreme dilatation of the heart to the right 
of the sternum. Distension of and pulsations in the 
veins of the neck occur with tricuspid regurgitation. 

Palpation. — The apex beat is diffuse, and most 
marked over the right ventricle and close to the sternum 



368 THE CIRCULATORY SYSTEM. 

and in the epigastrium. Over the base of the heart a 
diastolic thrill may be felt. Cardiac dullness is 
increased, and may be detected beyond the right 
edge of the sternum over the site of the pulsation. 

Auscultation. — A diastolic murmur is heard with 
the point of maximum intensity in the second left inter- 
costal space, with the area of diffusion downward along 
the sternum and to the apex of the right ventricle. The 
murmur may be harsh, rasping and superficial, espe- 
cially when associated with pulmonary obstruction, or 
soft and blowing when due to dilatation of the pul- 
monary artery. (Fig. 75.) 

Differential Diagnosis. — Pulmonic regurgitation is 
easily distinguished from aortic regurgitation when the 
two murmurs have their usual point of maximum inten- 
sity and area of diffusion. However, they may coincide 
in these respects. In pulmonic regurgitation the signs 
of hypertrophy and dilatation are limited to the right 
side of the heart; in aortic regurgitation the left ven- 
tricle is chiefly involved. In pulmonic regurgitation, 
dyspnoea and cyanosis, with clubbing of the fingers, are 
marked, also pulsations are noted in the veins. In 
aortic regurgitation the pulsations in the carotids and 
character of the pulse are distinctive. In pulmonic 
regurgitation a murmur is not heard in the vessels of 
the neck ; in aortic regurgitation a double murmur may 
be heard in the vessels of the neck and over the arteries. 

OBSTRUCTION AT THE TRICUSPID ORIFICE. 

Obstruction at the tricuspid orifice is one of the rarest 
cardiac lesions. Most of the cases are not recognized 
during life. Of the recorded cases, nearly 80 per 
cent, occurred in women. 

The obstruction is usually due to adhesions of- the free 
margins of the leaflets, converting the valve into a 
funnel-shaped structure, or reducing the opening to a 
mere slit. 



DISEASES OF THE HEART. 369 

Effect of Tricuspid Obstruction. — The effect varies 
according to the degree of obstruction, and may be 
limited to the right auricle or extend beyond to the 
venous circulation. When the stenosis is slight, hyper- 
trophy of the right auricle is frequently sufficient 
to overcome the obstruction to the flow of blood through 
the orifice. When the power of the auricle is insuffi- 
cient, interference with the return circulation occurs, 
causing congestion of the abdominal organs and effusion 
into the serous cavities. 

Physical Signs. — The physical signs present in tri- 
cuspid obstruction vary greatly. In some of the reported 
cases they were well marked, and in others indistinct. 
As in mitral obstruction, the murmur may be present 
at one time and absent at another. 

Inspection. — When the obstruction is slight and is 
compensated for by the right auricle, no change is noted. 
Interference with venous circulation is shown bv dis- 
tension of the superficial veins, especially of the neck. 
When pulsations occur they are synchronous with the 
auricular systole. There is also some duskiness of the 
skin and oedema. Effusion into the pleural cavity may 
cause change in the position of the apex beat. 

Palpation. — At times a thrill is felt. Its maximum 
intensity may be over the valve along the left border of 
the sternum, or at the apex of the right ventricle in the 
fifth interspace. It may occur in both locations at the 
same time with nearly equal intensity, or its maximum 
intensity may alternate, being first in one place, then in 
another. The radial pulse shows no change, except in 
marked obstruction, when it is rapid, irregular, small 
and compressible. Cardiac impulse may be normal or 
in marked obstruction, feeble and irregular. 

Percussion. — Very little change is produced, except 
that dilatation of the right auricle may increase the 
transverse area of percussion flatness at the level of the 
fourth rib. 

Auscultation. — The diagnostic sign of tricuspid 

24 



370 THE CIRCULATORY SYSTEM. 

obstruction is a pre-systolic murmur, with the point of 
maximum intensity over the lower portion of the 
sternum at the upper edge of the ensif orm cartilage. Its 
area of diffusion corresponds to the area of superficial 
cardiac dullness. The murmur may occupy the entire 
diastole, with accentuation just before the systolic im- 
pulse. (Fig. 69.) 

, Differential Diagnosis. — The distinctive features of tri- 
cuspid obstruction are absence of ventricular hypertro- 
phy, marked venous turgescence, the presence of a thrill 
and a pre-systolic murmur limited to the area occupied 
by the right ventricle. On account of its frequent asso- 
ciation with mitral obstruction, it is masked by the signs 
of that lesion. 

Mitral Obstruction. — Mitral obstruction has also 
a pre-systolic murmur, and inspection shows right ven- 
tricular hypertrophy, and, when venous overfilling is 
present, also hypertrophy and dilatation of the right 
ventricle. 

The thrill is more vibratory in quality, and is located 
at the apex, but its termination by ventricular systole is 
more definite. The murmur, although it may be heard 
during the major part of the diastole, has a pre-systolic 
accentuation more marked, and the murmur terminates 
with the short, intensified first sound. The maximum 
intensity is at the apex, but it is not diffused widely, 
and is never heard along the left border of the sternum 
or over the ensif orm cartilage (tricuspid area). 

The pulmonic second sound is accentuated in mitral 
obstruction, and indistinct in tricuspid obstruction. 

REGURGITATION AT THE TRICUSPID ORIFICE. 

Regurgitation at the tricuspid orifice occurs under two 
separate conditions. (1) It may be due (a) to vegeta- 
tions on the leaflets, preventing perfect coaptation, (b) 
to thickening, shrinkage or deformity of the leaflets, (c ) 
to induration and shortening of the chordae tendinea? 



DISEASES OF THE HEART. 371 

and papillary muscles. These structural changes are 
usually due to endocarditis and pericarditis which are 
likely to involve other valves besides, and are relatively 
rare at the tricuspid valve alone. 

(2) Incompetency at the tricuspid orifice is most fre- 
quently dependent on dilatation of the right ventricular 
cavity and the auriculo-ventricular ring, which becomes 
too large to be closed by the valves. Relative valvular 
insufficiency occurs much more readily at the tricuspid 
valve than at the mitral. There is abundant proof that 
there exists a safety valve action at the tricuspid orifice, 
and that slight temporary regurgitation occurs when- 
ever the pressure in the pulmonary artery reaches a 
certain height. Under normal conditions, the functional 
or physiological regurgitation that occurs under extreme 
exercise or exertion is temporary, disappearing with the 
return of the blood pressure to normal. When tricuspid 
incompetency from dilatation of the right ventricle is 
secondary to persistent high pressure in the pulmonary 
artery or obstruction at the pulmonary orifice, it is per- 
manent, and represents another broken link in the chain 
of cardiac compensation. 

The cause of high blood pressure in the pulmonary 
artery may be obstructive disease in the lungs (emphy- 
sema and fibroid changes) or lesion at the mitral orifice, 
either primary or secondary (see Mitral Regurgitation 
and Obstruction). When the relative insufficiency is 
due to transient increase of pressure in the pulmonary 
artery (as in acute bronchitis, over-exertion, etc.), or to 
temporary disturbance of cardiac nutrition (pyrexia, 
toxines, anaemia, etc.), the dilatation may become less 
and the valves again become competent to close the 
orifice with the disappearance of the disturbing factors. 
Effect of Tricuspid Regurgitation — The immediate effect 
is upon the right auricle, which may become dilated to 
an enormous extent. The secondary hypertrophy is 
never very marked, and is always inadequate to com- 
pensate for the lesion. The great veins become dilated, 



372 THE CIRCULATORY SYSTEM. 

the inferior vena cava more so than the superior. The 
valves protecting the veins at the root of the neck be- 
come incompetent. Venous stasis causes general oedema. 
One of the earliest effects of tricuspid regurgitation is 
enlargement of the liver and the occurrence of ascites 
and hydrothorax. 

Physical Signs. Inspection. — As an isolated lesion, 
the apex beat is displaced inward toward the median 
line, and may be beneath the sternum or in the epigas- 
trium. Impulses due to auricular systole may be seen 
in the third and fourth interspaces to the right of the 
sternum. When secondary to left-side cardiac disease, 
the apex is displaced downward and outward, and also is 
seen in the epigastric region. When secondary to em- 
physema, distension of the lung causes the epigastric 
pulsation to be specially prominent. Cyanosises usually 
present. In long-continued interference with return 
circulation clubbing of the fingers occurs. Systolic 
venous pulsations are present in the jugulars, most 
marked on the right side. In marked cases pulsation of 
the liver may be seen. The respiratory movements are 
increased unless hydrothorax occurs, when there will be 
loss of motion over the lower portion of the thorax. 

Palpation. — Cardiac enlargement corresponds to 
that noted by inspection. When tricuspid regurgitation 
is a primary disease, the epigastric pulsations are weak 
and undulatory. W 7 hen secondary to cardiac or pul- 
monary changes, the pulsations are more forcible and 
heaving. When the ear is placed over the tricuspid 
area a characteristic wavy impulse is detected in addi- 
tion to the murmur. Hepatic pulsations are one of the 
diagnostic signs, and must be differentiated from im- 
pulse transmitted to the liver from the aorta or the en- 
larged right ventricle. Pressure on the liver in tricuspid 
regurgitation increases jugular pulsations. 

Percussion. — The cardiac area is enlarged to the 
right. Dullness may be detected beyond the right bor- 
der of the sternum at the level of the fourth rib. 



DISEASES OF THE HEART. 373 

Auscultation. — The murmur of tricuspid regurgi- 
tation is systolic, soft, blowing, with the point of maxi- 
mum intensity along the sternum at the junction of the 
fifth and sixth costal cartilages. The area of diffusion 
corresponds to the extent of the praecordia. It does not 
oxtend above the third rib nor beyond the apex. The 
intensity of the murmur is increased during expiration, 
and is diminished or absent during inspiration. The 
second sound varies. When tricuspid regurgitation is 
primary it is weak and indistinct. When secondary to 
increased pressure in the pulmonary artery, the second 
sound is accentuated. (Fig. 70.) 

Differential Diagnosis. — The distinctive features of tri- 
cuspid regurgitation are extension of the cardiac area to 
the right, systolic pulsations in the veins and liver, and a 
soft, blowing, systolic murmur, with the point of max- 
imum intensity over the site of the tricuspid valve and 
heard over the praecordia. "A systolic tricuspid mur- 
mur is often heard as far out as the apex, and occasion- 
ally has its maximum intensity just to the inner side of 
the apex. When a systolic murmur heard at the apex is 
lost immediately to the left of the boat, while audible 
between the apex and the lower end of the sternum, its 
seat of production is at the tricuspid and not at the 
mitral orifice." — (Broadbent.) It is to be differentiated 
from other lesions characterized by a systolic murmur. 

Mitral Regurgitation.' — In mitral regurgitation the 
murmur is heard with the point of the maximum in- 
tensity at the apex, and it is carried beyond the prae- 
cordia to the left into the axilla, and is heard behind. 
The thrill is vibratory and distinctly pre-systolic. The 
apex is displaced to the left and downward. 

Aortic Stenosis. — The svstolic murmur is heard above 
the third rib, and is carried up into the vessels of the 
neck. It is also associated with characteristic pulse. 

Pulmonic Obstruction. — In pulmonic obstruction the 
point of maximum intensity and the area of diffusion 
are diagnostic. (Fig. 72.) 



374 



THE CIRCULATORY SYSTEM. 



DISEASES OF THE MYOCARDIUM. 

Hypertrophy and Dilatation. 

Hypertrophy of the cardiac muscle may occur in two 
forms 1 — (1) simple hypertrophy, (2) hypertrophy with 
dilatation of the cavity, or eccentric hypertrophy. It 
may be limited to the walls of a single cavity, or may 



Fig. 89. 




Cardiac hypertrophy, cor bovinum of chronic nephritis. 

be general. Cardiac dilatation is also divided into two 
forms 2 — (1) simple dilatation, in which there is in- 
crease in the size of the cavity, with thinning of the 
wall; (.2) dilatation with hypertrophy, in which, with 
enlarged size of the cavity, there is increase in the rela- 
tive thickness of the heart wall. In both eccentric 



1 Concentric hypertrophy characterized by increase in thickness in 
the walls of the cavity with diminution of its size is rarely recognized 

during life. 

2 Atrophic dilatation has been described dependent on wasting of 
the cardiac muscle coincident with increase in size of the cavity. 



DISEASES OF THE HEART. 375 

hypertrophy and dilatation with hypertrophy we have 
increase in the size of the cavity, with increase in thick- 
ness of the heart muscle. The distinction between these 
two conditions depends upon the relative efficiency of the 
cardiac muscular power to the dilatation. When the 
working power of the heart is increased beyond what is 
needed to overcome the cause and effect of the dilatation, 
it is classified as eccentric hypertrophy. When, on the 
other hand, dilatation is predominant, and the increased 
muscular tissue barely compensates for the dilatation, it 
is classified as dilatation with hypertrophy. 

Physical Signs.- — Cardiac dilatation and hypertrophy 
are generally secondary conditions. 

The physical signs present in the different forms are 
fully described under "Inspection," "Palpation," "Per- 
cussion" and "Auscultation;'' also under the diagnosis of 
the different valvular diseases and chronic myocarditis. 

Acute Myocarditis. 

This may exist in two forms, (1) as an acute degen- 
eration of the muscle tissue of the heart dependent upon 
infectious fevers (cloudy swelling, parenchymatous 
myocarditis) ; (2) as an inflammatory afTecrion of the 
interstitial tissue of the heart, which may also be due to 
infectious diseases, or may be secondary to acute inflam- 
mations of the pericardium or endocardium. 

Localized or suppurative myocarditis may result from 
infection from micro-organisms, secondary to suppura- 
tions in distant portions of the body, or due to extension 
from infectious endocarditis. 

Physical Signs. — The physical signs present, are those 
indicative of defective muscular power, with varying 
decrees of dilatation. The earliest change noted is fee- 
bleness of the cardiac impulse, both to inspection and 
palpation. Auscultation shows gradual diminution in 
the muscular element of the first sound, with accentua 
tion of the aortic and pulmonic sounds. When dilata 
tion occurs, the murmurs of mitral and tricuspid regur- 
gitation may be present. 



376 THE CIRCULATORY SYSTEM. 

Chronic Myocarditis. 

Chronic changes in the myocardium may be due to 
(1) fatty degeneration of the muscle tissue: (2) fibroid 
degeneration (fibroid or interstitial myocarditis) ; (3) 
fatty overgrowth (fatty infiltration or cor adiposum). 

Physical Signs. — The physical signs in disease of the 
myocardium are those of weak heart, "weak in muscle 
power and weak in its resistance to blood pressure;" 
signs of hypertrophy and dilatation are usually present 
in varying degree, according to the cause of the condi- 
tion. 

Inspection. — The apex beat of the heart may be in 
the normal position, or displaced; when the changes in 
the myocardium are secondary to sclerosis or atheroma 
in the blood-vessels, the apex beat will be displaced out- 
ward and to the left in proportion to the hypertrophy 
and dilatation. With insufficiency of cardiac power, the 
patient shows disturbances of the superficial circulation 
and slight blueness of the extremities. Atheroma of the 
blood-vessels is shown by prominence of the temporal 
and other arteries. In fatty overgrowth there is asso- 
ciated obesity. 

Palpation. — The location of the impulse depends 
upon the presence of hypertrophy and dilatation. In 
fatty degeneration the impulse is feeble and diffused. 
When associated with hypertrophy, especially of the 
fibroid type, the impulse, while heaving, lacks a lifting 
force proportionate to the size of the heart. The pulse is 
weak in comparison to the seeming effort of the heart. 
When cardiac power is insufficient, arrhythmia occurs, 
which may be constant or induced by slight exertion. 

Percussion. — The dimensions of the heart are in- 
creased with hypertrophy and dilatation in all direc- 
tions. When dilatation is predominant, percussion 
dullness extends above the third interspace and to the 
nipple line or beyond it. (Pig. 90.) In fatty over- 
growth the percussion area of the heart is increased. 



DISEASES OF THE HEART. 



377 



Frequently it is impossible to map out the heart on 
account of the thickness of the superficial tissue. 

Auscultation. — The characteristic sign is a short, 
feeble first sound at the apex, with a relatively louder 
second sound over the aorta. The pulmonic second 
sound is not increased in intensity. Usually there is 
reduplication of the first sound. With the occurrence 

Fig. 90. 




Cardiac dilatation of chronic myocarditis. 

of dilatation and valvular incompetency, soft, blowing 
murmurs are heard in the mitral and tricuspid areas. 

Diagnosis of myocarditis rests upon the above physi- 
cal signs, associated with other evidence of insufficiency 
of muscular power, as dyspnoea, oppression in the chest, 
or anginal pain on exertion and after meals, syncope 
with cardiac irregularity. 



CHAPTER XIII. 

DIAGNOSIS OF THE DISEASES OF THE PERICARDIUM. 

The smooth surfaces of the pericardium, lubricated 
by the normal secretion of the serous membrane, glide 
over each other during the cardiac and respiratory 
movements' without producing any vibrations which can 
be detected by palpation or heard as a friction sound. 
The amount of secretion contained in the pericardial 
sac in health varies within verv narrow limits, and is 
never present in such quantity as to be detected by 
physical examination. Pericardial diseases produce 
distinctive physical signs, according as the normally 
smooth surfaces are altered so as to produce vibrations 
which may be felt or heard, or the sac is distended by 
fluid. 

Pericarditis. 

According to the nature of the changes in the peri- 
cardial sac, three forms of pericarditis can be recognized 
by physical signs, irrespective of their aetiology.*' The 
morbid conditions of each form may exist separately or 
may be combined in varying degrees, and due to widely 
differing causes. As a number of non- inflammatory 
conditions of the pericardium may produce changes 
similar to those due to the inflammation, and as the 
physical signs depend upon the altered state of the sac, 
they will be described with the different forms of peri- 
carditis. 

(1) Dry, Elastic or Fibrinous Pericarditis. — In this form 
the surfaces may be abnormally dry from diminished 
secretion, dependent upon loss of blood or fluid from the 
bodv, or changes in the serous membrane during the 



DISEASES OF THE PERICARDIUM. 379 

early stage of inflammation. Later during the inflam- 
matory attack the surfaces may be covered with thick, 
tenacious exudate (fibrinous or plastic). The surfaces 
may also be roughened by fibrous, tubercular or malig- 
nant growths. The physical signs will vary according 
to the nature of the change. 

(2 ) Effusion into the Pericardium, Pericarditis with Effusion. 
— The. fluid poured into the sac may be sero- fibrinous, 
serous, purulent or hemorrhagic. Serous effusion, 
small in amount, may exist with a fibrinous exudate 
which coagulates on the surfaces, while the more liquid 
element gravitates to the bottom of the sac (sero-fibrin- 
ous pericarditis). The liquid element (serum) of the 
inflammatory exudate may be excessive and rapidly fill 
the pericardial sac without the occurrence of the dry, 
or plastic stage. Serous effusion into the pericardium 
occurs as part of a general dropsy and interference with 
the return circulation (hydro-pericardium), and is un- 
attended with any inflammatory changes. It usually 
accompanies effusion into other serous sacs. 

Purulent effusion may occur primarily, as in septic 
disease, or be due to secondary changes in sero-fibrinous 
or serous inflammatory pericarditis. Hemorrhagic 
effusion (hsemo-pericardium) may be inflammatory or 
be dependent upon new growths, blood condition 
(scurvy, purpura), rupture of the heart or of a cardiac 
aneurism. 

The physical signs present in effusion are in propor- 
tion to the amount of fluid and the effect of the enlarged 
pericardium upon the heart and surrounding organs. 
The nature of the fluid does not modify the physical 



S12TLS. 

o 



(3) Pericardial Adhesion. Adherent Pericardium. — This 

is usually secondary to inflammatory diseases of the 
pericardium. It may be limited to a few bands loosely 
stretched between the two surfaces and not interfering 
with the cardiac action; or the two surfaces may be 
closely united, or the sac may be completely obliterated, 



380 THE CIRCULATORY SYSTEM. 

in which case the movements of the heart will be entirely 
or in part restricted and secondary hypertrophy or dila- 
tation with hypertrophy will occur. 

Physical Signs. — As the three forms of pericarditis 
may be variously combined, or follow each other during 
the course of an attack of pericarditis, they will be con- 
sidered together. 

Inspection. Dry, Plastic or Fibrinous Form. — 
There is no change in the contour of the praecordia. 
The apex beat is in the normal position, the impulse 
more forcible, due to cardiac irritability. When asso- 
ciated with myocarditis, the impulse is weaker and more 
diffused. 

Effusion into the Pericardium. — Change in the 
praecordia will be in proportion to the quantity of 
fluid and the elasticity of the chest walls. The effects 
on the shape and size of the thorax will be most 
noticed in thin persons and in children, and may be 
masked in stout persons. The apex beat is seen at a 
higher point on the chest wall, according to the amount 
of fluid present. This is not due to elevation of the 
anatomical apex, but to the changed relation of the 
anterior portion of the heart to the chest wall, so that a 
point nearer the base of the heart strikes the chest wall 
and gives the visible and palpable apex beat, (a) Small 
effusions may produce no change in the praecordia. The 
apex beat is displaced inward and slightly elevated, (b) 
In medium-sized effusions the intercostal spaces along 
the left side of the sternum, from the third to the sixth, 
are filled out, and may be slightly bulging. The thorax 
over the apex is slightly enlarged, (c) In large effusions 
the bulging over the praecordia is marked, and the lower 
end of the sternum is pushed out ; the epigastric region 
is more prominent, the costal cartilages and ribs are 
elevated, and the intercostal spaces on both sides of the 
sternum are wider, the normal depressions being absent. 
The changes in the lower portion of the chest are due to 
diminished negative pressure within the thorax and de- 



DISEASES OF THE PERICARDIUM. 381 

pression of the diaphragm and liver by the weight of the 
fluid. The visible impulse is usually seen above the 
fourth rib. In extreme distension pericardial bulging 
may extend as far as the second rib. 

Enlargement of the pericardial sac causes reduction 
of the negative pressure within the chest, and allows of 
the elevation of the bony thorax and changed relation 
between the ribs individually, and especially between 
the first rib and the clavicle. Ewart has called attention 
to the changed relation between the clavicle and the first 
rib (first rib sign) as important in diagnosis of effusion 
of considerable amount. The left clavicle is raised to a 
higher level, so that the upper edge of the first rib on the 
left side can be felt as far as its sternal attachment. 
When the amount of fluid is sufficient to produce a posi- 
tive pressure, instead of the normal negative pressure 
in the pericardium, cyanosis occurs, also pulsations in 
the veins of the neck, due to auricular contraction. 

The effect of posture on the apex beat in effusion is 
the opposite of what occurs in other conditions, causing 
an elevation of the apex beat. When the patient is on 
the right side, the apex beat becomes lower and more 
distinct; in other conditions it is higher, weaker or 
absent. 

Adherent Pericardium. — Flattening of the chest over 
the lower portion of the praecordia usually occurs. Occa- 
sionally there is bulging, due to hypertrophy and dilata- 
tion of the heart. "Svstolic retraction of some of the 
lower ribs on the lateral or posterior aspect of the 
thorax." — (Broadbent). The respiratory movements are 
altered when extensive pericardial changes are present. 
With inspiration there is loss of expansion over the 
lower portion of the left chest below the horizontal 
nipple line, and drawing in of the end of the sternum. 
Protrusion of the abdomen, and frequently ascites, may 
occur. The apex beat is displaced outward and down- 
ward or elevated as high as the fourth rib, according as 
the heart is hypertrophied or dilated or fixed by adhe- 



382 



THE CIRCULATORY SYSTEM. 



sions in an abnormal position. The apex beat does not 
vary with change in the posture of the patient. The 
diastolic rebound of the heart may be visible. Diastolic 
collapse of the veins is occasionally seen. 

Palpation. — Dry, Plastic or Fibrinous Pericarditis. 
— The cardiac impulse may be increased. Friction 
fremitus is felt over different portions of the prsecordia 



Fig. 91. 




Adherent pericardium, with dilatation and regurgitation at mitral 

orifice. X-Ray outline of heart. 
* Shows areas of Broadbent sign. 

in a small proportion of cases ; it is most readily detected 
by making moderate pressure in the intercostal spaces 
with the finger tips. The rhythm of the fremitus 
generally corresponds with the systole, but may extend 
into the diastolic period or be confined to it. It does 
not have a well-defined or stable point of maximum 
intensity, but varies in different cases and in the same 



DISEASES OF THE PERICARDIUM. 



383 



case at different times, although it is more frequent and 
persistent over the base of the heart. The area over 
which it is felt is usually the circumscribed point of 
maximum intensity ; occasionally it is felt over the entire 
prsecordia, and may be perceptible in widely separated 
spots. The fremitus gives the sensation of being super- 
ficial and produced by the rubbing together of dry, 

Fig. 92. 




Adherent pericardium, showing area of Broadbent sign and mitral 
murmur at back. X-Ray outline of heart from behind. 



rough or sticky surfaces. In acute cases the friction 
fremitus is present for a short time only, and varies 
from day to day in situation, extent and character. 

Effusion into the Pericardium. — Friction fremitus, 
usually absent over the lower portion of the prrecordia, 
may be detected above the fourth rib and over the site 
of the great vessels. Cardiac impulse is felt at a higher 
level, and is more diffused according to the amount of 



384 THE CIRCULATORY SYSTEM. 

diffusion. Fluctuation over the prsecordia may be 
present when the amount of fluid is sufficient to give 
positive pressure in the pericardium. Diminution in 
the amount of fluid causes the cardiac impulse to he felt 
at a lower point, and to become more defined. Removal 
of the fluid is frequently attended with reappearance of 
friction fremitus. 

Adherent Pericardium. — In addition to the abnormal 
movements of the chest wall noted in inspection, the 
cardiac impulse frequently gives the sensation of being 
abnormally close to the chest wall. According to the 
situation and extent of the adhesions and the secondary 
changes in the heart (hypertrophy or dilatation), the 
impulse will be displaced to various portions of the 
prsecordia, and will be strong, diffused or of a more 
undulating character or "a tug on the false ribs during 
the cardiac systole, and a sharp rebound which can be 
felt as well as seen when the hand is laid flat on the 
chest wall at the spot." — (Broadbent.) 

Percussion. — Dry, Plastic or Fibrinous Pericarditis. 
— No change in the area of superficial flatness or rela- 
tive dullness is detected unless myocarditis with dilata- 
tion is present. The extreme edge of cardiac dullness 
corresponds closely to the apex beat. 

. Effusion into the Pericardium. — The most distinctive 
sign of pericardial effusion is change in the extent and 
outline of the area, of cardiac flatness and dullness and 
their relation to each other. These changes can be 
detected by careful and systematic percussion when but 
a small quantity of fluid is present. The area of flatness 
increases, while that of relative dullness diminishes* As 
the pericardium increases in size, change in the inter- 
thoracic pressure (negative pressure) allows that por- 
tion of the lungs which normally covers the pericardium 
to retract, so that there is not the gradual change from 
normal pulmonary resonance to cardiac flatness. In 
extreme distension of the pericardium, the change in 
the intrathoracic pressure may be sufficient to cause 



DISEASES OF THE PERICARDIUM. 385 

diminution of function in different portions of the lungs, 
with characteristic pulmonary resonance. A small effu- 
sion causes change in the percussion area, most marked 
at the level of the fifth rib. (a) To the left the flatness 
extends to the site of the normal apex beat or slightly 
beyond. The area of relative dullness in this region is 
decreased, (b) At the right of the sternum dullness is 
detected in the fifth intercostal space (cardio-hepatic 
triangle), and the cardio-hepatic triangle becomes more 
obtuse (Rotch's sign). As the fluid increases in amount, 
the area of flatness extends in all directions, especially 
laterally, at the lower level of the pericardium. With 
the increase in extent, the contour of the pericardial flat- 
ness also changes, becoming more pyramidal, with the 
two sides meeting the base at nearly equal angles. More 
marked distension causes the lower segment of the peri- 
cardium to be more globular and the upper portion more 
cylindrical, so that the typical pear-shaped outline ob- 
tains. Sternal resonance is altered by the effusion. As 
the sac becomes filled the resonance becomes impaired, 
and is later replaced by flatness. The change in loss of 
resonance occurs from below upward, in contradistinc- 
tion to that occurring in aneurism of the aorta. The 
percussion note over the lung is changed according to the 
amount of fluid present. As the fluid increases, the en- 
larged pericardium allows retraction in the overlapping 
lung and diminution of tension, so that the normal pul- 
monary resonance is replaced by a tympanitic quality 
(Skoda's resonance), which in large effusion may be 
present over the apex of the lung on the left side. 

"Whenever fluid is effused into the pericardium, the 
normal resonance is modified at the left posterior base 
in the most definite way. A patch of marked flatness is 
found at the left inner base, extending from the spine 
for a varying distance outward, usually not quite so far 
as the scapular line, and ceasing abruptly with the 
vertical boundary. Above, its extension is also variable, 
according to the size of the effusion. Commonly it dogs 

35 



386 THE CIRCULATORY SYSTEM. 

not extend higher than the level of the ninth or tenth 
rib, and here, again, its horizontal boundary is abrupt. 
Its shape is that of a square, and is quite unlike that of 
any dullness arising from pleuric effusion." (Ewart.) 

Over the liver, the upper limit of both dullness and 
flatness is lowered; the lower edge of the liver is below 
the free border of the ribs in proportion to the depres- 
sion of the diaphragm. 

Adherent Pericardium. — Changes in thickness of the 
pericardium do not affect the percussion area. Any 
alteration in size or shape is due to the presence of 
hypertrophy, dilatation or displacement of the heart. 

Auscultation. Dry, Plastic or Fibrinous Pericar- 
ditis. — The diagnostic sign of this form is the friction 
sound. The quality of the friction sound varies 
according to the condition of the pericardial surfaces. 
It may be soft and murmurish, simulating an endocar- 
dial murmur; soft, dry, grazing or brushing, as when 
the dry finger tips or pieces of silk are gently rubbed 
together close to the ear ; sticky ; or harsh, creaking or 
grating, as when new leather is bent. In addition to 
the friction quality, the sensation of being superficial is 
a distinctive feature. The rhythm of the friction 
sound, while dependent upon cardiac movement, is not 
accurately limited to the periods of the normal cardiac 
sounds, but by extending beyond them it gives a double 
or to-and-fro rhythm, which is characteristic of peri- 
cardial friction. The point of maximum intensity is 
not stable, and the sound is not conducted beyond the 
prsecordia except in rare cases, when the conduction is 
due to change in the surrounding lung tissue. 

The friction sound may be heard over any portion of 
the prsecordia, but its most persistent site is over the base 
of the heart, opposite the third and fourth ribs on 
the left side. The intensity of the sound is influenced 
by (a) pressure, (b) position, and (c) respiratory move- 
ments in a rather characteristic way. (a) Pressure over 
the prsecordia causes the friction sound to be heard ; 



DISEASES OF THE PERICARDIUM. 



387 



or, when present, to become more intense and audible 
over a wider area and for a longer period of time; it 
also increases the to-and-fro character, and emphasizes 
its want of synchronism with the normal cardiac sounds. 
(b) Posture. Bending the body forward, so that the 
heart comes in contact with the anterior portion of the 
pericardium, affects the friction sound in the same 
manner as pressure. It intensifies the sound, and in- 



Fig. 93. 




Friction in dry pericarditis. 

creases the area over which it is heard, (c) Respira- 
tory movements. The intensity, quality and extent of 
the friction sounds change during inspiration and ex- 
piration. In some cases the increase in these features 
occurs during inspiration, and at others during expira- 
tion. The significant fact is that the sound is altered 
to a marked degree during either inspiration or expira- 
tion. Variability from day to day in the site, rhythm, 



388 THE CIRCULATORY SYSTEM. 

intensity and quality is a distinctive feature of peri- 
cardial friction sounds. 

Effusion into the Pericardium. — As fluid accumu- 
lates, there is disappearance of the friction sound, as 
there was of friction fremitus, over the lower portion of 
the pericardium except when separation of the anterior 
surface of the heart from the pericardium is prevented 
by adhesions. At the base, and especially where the 
pericardium is reflected along the great vessels, the 
friction sounds may persist during the entire course. 
The cardiac sounds over the site of the normal apex are 
weak or inaudible, and are more distinctly heard toward 
the base of the heart over the site of the visible impulse. 
The pulmonic second sound may be increased. 

The respiratory sounds are also modified. The res- 
piratory murmur and vocal fremitus along the^ normal 
site of the anterior border of the lung, especially on 
the left, are feeble or absent. Bronchial breathing and 
segophony may bs heard below the right nipple and be- 
hind at the angle of the left scapula in large effusions. 

If the patient lies with face downward, or leans for- 
ward on the knee and elbow, the dullness and bronchial 
breathing in the back disappear. With absorption of 
the fluid, the friction sound may return, and there will 
be early disappearance of the respiratory signs. 

Cardiac sounds are heard in the normal site and Avith 
normal intensity when myocardial changes have 

occurred. 

Adherent Pericardium. — The auscultatory signs are 
not distinctive, and depend on the condition of the sur- 
faces and the degree of change produced in the heart 
and at the valvular orifices. A rough pericardial fric- 
tion sound may be heard over different portions of the 
prsecordia, especially the base. The cardiac sounds 
may vary greatly. The first sound may have the 
valvular quality accentuated or may be doubled; the 
second sound may be reduplicated and accentuated. 
Both sounds may be heard abnormally clear behind. 



DISEASES OF THE PERICARDIUM. 389 

Endocardial murmurs, due to dilatation of the cavities, 
may be present. 

Differential Diagnosis. — The distinctive features of 
acute, dry, fibrinous pericarditis are friction fremitus 
and friction sound of marked superficial, rubbing qual- 
ity, with no fixed point of maximum intensity. The 
sound does not coincide with the areas of the normal 
valve sounds nor with the areas of endocardial mur- 
murs, and it is not transmitted beyond the praecordia. 
Its rhythm is not accurately synchronous with the 
periods of the cardiac sounds, but has a double, to-and- 
fro character. The intensitv of the sound varies during 
the respiratory movements, and is increased by pressure 
over the prsccordia, and is loudesl when the patient is 
erect or bending forward. There is no evidence of 
cardiac enlargement. 

Acute Endocarditis and Chronic Valvular Disease. — 
The thrill present in endocardial diseases is localized at 
the apex (mitral obstruction) or at the base (aortic 
stenosis or regurgitation). It has a definite relation to 
the rhythm of the cardiac sounds, and does not give the 
impression of being superficial. The endocardial mur- 
murs have a definite area of maximum intensity and 
area of diffusion. Murmurs made at certain valves are 
heard beyond the prsecordia. The intensity of the 
murmur is not altered by pressure. Systolic murmurs 
are loudest in the recumbent posture and fainter in the 
erect. In chronic valvular disease, hypertrophy and 
dilatation of the heart are present. 

Pleuritic Friction and Pleuro-pericardial Friction 
Sounds. — Friction sounds made in the pleura by the 
movement of the heart may simulate those of pericar- 
ditis. They are distinguished by the effect of respira- 
tion on the intensity and quality of the sound. On deep 
inspiration, the sound is intensified. When the patient 
takes a full breath and holds it, the sound disappears. 

Effusion into the Pericardium. — The distinctive 
features of effusion into the pericardium are that the 



390 THE CIRCULATORY SYSTEM. 

visible cardiac impulse is raised; the lower portion of 
the prsecordia is fuller than normal; the intercostal 
spaces are wider and smoothed out, or even bulging, 
according to the extent of the effusion, and pulsations 
may be noted above the fourth rib. The percussion 
area of cardiac flatness is increased, and extends to the 
left beyond the normal site of the apex beat. To the 
right there is at first dullness in the fifth interspace, 
with gradual extension to the right of the sternum ; the 
area of relative deep-seated cardiac dullness is dimin- 
ished, with a sharp line of demarcation between pul- 
monary resonance and cardiac flatness. The outline of 
the cardiac flatness becomes more pyramidal or pear- 
like. The sternal resonance is impaired from below 
upward in proportion to the distension of the peri- 
cardium. On auscultation, the cardiac sounds are 
feeble or absent over the apex, but are heard more 
clearly toward the base. Friction sounds over the base 
of the heart may be sometimes detected. Over the lung, 
the normal vocal fremitus and respiratory murmur are 
absent over the normal position of the anterior border. 
In extensive effusion areas of bronchial breathing are 
found in the right intermammary region in front, and at 
the angle of the left scapula behind. 

Dilatation and Hypertrophy of the Heart. — The 
visible, palpable apex beat is carried downward and to 
the left. Left ventricular hypertrophy causes forcible 
apex beat ; in right ventricular hypertrophy the apex 
beat is diffused, and is seen and felt also in the epigas- 
trium. When dilatation predominates the impulse is 
feeble and diffused, but felt at the lower portion of the 
prsecordia and in the epigastrium. 

Dullness does not extend beyond the apex beat to the 
left, nor flatness beyond the right of the sternum. The 
normal sternal resonance is but slightly impaired. 
There is relative greater increase in the area of dullness 
over that of flatness. 

The cardiac sounds are heard distinctly at the apex. 



DISEASES OF THE PERICARDIUM. 391 

When hypertrophy and dilatation are due to valvular 
lesions, the characteristic murmurs are present. 

Effusion into the Left Pleura. — In this condition dis- 
placement of the heart to the right gives elevation of the 
impulse and dullness or flatness to the right of the 
sternum. But the flatness on the left side extends be- 
yond the prsecordia, and has its highest point in the 
axillary line, and is noted behind. Bronchial breath- 
ing, when present, is above the level of the fluid, but not 
at the angle of the scapula. 

Adherent Pericardium. — The characteristic feat- 
ures of adherent pericardium are flatness of the chest 
over the lower portion of the praecordia, with systolic 
retraction over the apex or other portions of the praecor- 
dia, according to the seat of adhesion, associated with 
diastolic rebound, and at times diastolic collapse of the 
veins*. Rough, creaking pericardial friction sounds may 
be present. 

There are no pathognomonic signs of this condition, 
and diagnosis rests on the relation of the physical signs 
to each other. 

Cardiac Hypertrophy and Dilatation. — Systolic 
retraction over the apex may be present in massive 
cardiac hypertrophy with adhesions between the peri- 
cardial sacs. It is distinguished from adherent peri- 
carditis by the history of the case, and the presence of 
valvular lesions causing the hypertrophy. 

Pneumopericardium. 

Gas in the pericardium may be due to the decomposi- 
tion of the fluid contents or to perforation of the peri- 
cardium, which may be traumatic or may be due to 
ulceration from air-containing spaces. 

Physical Signs. Inspection. — Distension of the peri- 
cardium causes bulging over the prsecordia. The apex 
beat is weak or absent, and is most marked when the 
patient bends forward. 



392 THE CIRCULATORY SYSTEM. 

Palpation. — Emphysematous crepitations may be 
present. Succussion splash may be felt with movement 
of the heart when air and fluid are present. 

Pebcussion. — The percussion sounds are most dis- 
tinctive. Over the pericardium there is a tympanitic 
percussion note, frequently with a ringing, metallic 
quality. Cracked-pot resonance may be present on 
forcible percussion when there is free opening. The 
percussion note over the prsecordia varies with the 
posture of the patient. In the recumbent posture the 
entire prsecordia is resonant. When the patient stoops 
forward, bringing the heart against the chest wall, a 
small zone of dullness may be detected. When fluid and 
air are in the pericardium, flatness may be present over 
the lower portion of the pericardium and tympanitic 
resonance above. The line of flatness changes with the 
position of the patient. 

Auscultation. — The character of the sounds vary 
according to the presence of air alone or of air and fluid 
in the pericardium. With air alone, or if there is but 
little fluid, the heart sounds have a loud, ringing, metal- 
lic quality. When the cardiac action produces move- 
ment of the fluid, metallic splashing or churning (water 
wheel) sounds are present. Endocardial murmurs, 
when present, are intensified by reverberation in the 
pericardium. 



CHAPTER XIV. 

DIAGNOSIS OF DISEASES OF THE BLOOD-VESSELS. 



ANEURISM OF THE AORTA. 

Dilatation of the aorta occurs in two forms: (1) 
Fusiform or cylindrical. In this form, at the seat of 
the dilatation, there is increase of the lumen of the 
artery in all directions without the occurrence of pouch- 
ing at any point, and unattended by the formation of 
any tumor or by pressure symptoms, even when the other 
physical signs of dilatation are very marked. To this 
form belong those general dilatations of the aorta and 
of the arteries given off from the arch, which may be due 
to changes primarily in the blood-vessels (aortitis, 
atheroma, etc.) or secondary to regurgitation at the 
aortic orifice. This form persists for a long time in a 
stationary condition, and beyond pulsation over the 
course of the artery, and the thrill and the murmur due 
to the enlarged lumen of the tube give rise to no 
secondary symptoms. 

Acute dilatation of the blood-vessel frequently occurs 
in inflammatory conditions of the aorta. It may dis- 
appear under rest and treatment, or may remain as a 
permanent dilatation. 

(2) Sacciform or circumscribed form. This is due 
to dilatation involving a part only of the circumference 
of the wall of the artery, with the formation of a circum- 
scribed tumor whose cavity is connected with the lumen 
of the artery by an opening of varying size, but the 
diameter of the opening is smaller than that of the 
aneurismal sac. 

The aneurismal tumor, filled with coagulated or fluid 



394 



THE CIRCULATORY SYSTEM. 



blood, produces physical signs and symptoms which are 
in part due to the tumor itself and in part dependent, 
upon its pressure upon the bony thorax, the heart, 
oesophagus, trachea, bronchi, lungs and. mediastinal 
structures. The signs and symptoms of aneurism vary 
according to the size and situation of the tumor and the 
direction of its pressure. 



Table of Pressure Signs in Aneurism. (Sanson.) 

Pressure of the bony thorax causes 



Local pain. 

Local oedema (pulsation). 

Absorption of tissue. 



Pressure on nerve causes 



Pressure on blood-vessel causes 



4 



f Unequal pupils, pa- 

Paralysis^ ral ^ sis °* v0 .° 1 al 
J cords. Hemiple- 

[ gia or paraplegia. 

Asthmatic dyspnoea. 

f Inequality of pulses. 

( Local cedemas. 
Obstruction of < Enlarged col- 
veins. I lateral veins. 



Pressure on air tubes causes 



Tracheal signs < 



Paroxysmal 

dyspnoea. 
Brassy cough . 
Bilateral 

stridor. 



Bronchial 



signs 



Also paroxys- 
mal dyspnoea 
and cough. 

Unilateral 

stridor. 

Filling or con- 
solidation of 
lung behind. 



Pressure on lung causes . . 
Pressure on oesophagus causes 



■{ Consolidation and displacement 
-j Dysphagia. 



Physical Signs. Inspection. 1. Ascending Portion 
of the Arch. — Bulging of the thorax and pulsating 
tumor are present to the right of the sternum in the 



DISEASES OF THE BLOOD-VESSELS. 395 

second and third intercostal spaces, except when the 
aneurism projects upward and inward from the lesser 
curvature. The apex beat of the heart may be in the 
normal position or be displaced downward. Pressure 
upon the superior vena cava" causes distension of the 
superficial veins of the chest and localized cyanosis or 
oedema of the right side of the face or of the upper 
extremities. Pressure upon the sympathetic nerve 
causes contraction of the right pupil. Pressure upon 
the right or left bronchus causes diminished expansion 
of the corresponding side of the chest. 

2. Transverse Portion of the Aorta. — Bulging of the 
upper portion of the sternum, with diffuse pulsation 
most marked in the epigastric notch and in the arteries 
of the neck. Pulsating tumor is present when erosion of 
the ribs or sternum occurs. (Figs. ( .>1 and 95.) Trachea 
displaced backward or laterally. Apex beat is gener- 
ally in normal position. Pressure upon left bronchus 
causes restricted motion of the left side. Pressure on 
the sympathetic nerve causes contraction of the pupil on 
the affected side. 

3. Descending Portion of the Arch and Upper Por- 
tion of the Descending Aorta. — AVhen the sac develops 
on the anterior surface there is bul^in^ of the inter- 
costal spaces to the left of the sternum. The apex beat 
is displaced to the right, and two areas of pulsation are 
seen. When it develops on the posterior surface, there 
is absorption of the ribs and vertebra?, with pulsations in 
the interscapular space. 

Jf. Descending Aorta, Inferior Position. — Enlarge- 
ment of the lower portion of the chest, displacement of 
the heart upward and to the right, diffuse pulsations in 
the epigastrium and toward the left. Loss of respira- 
tory motion over the lower ribs. 

5. Abdominal Aorta. — Pulsating tumor in the 
abdomen, frequently causing pulsations also over the 
hepatic area. 

Palpation. — By palpation a dilating or expansile 



396 



TEE CIRCULATORY SYSTEM. 



impulse is felt over the aneurism, and associated with a 
well-marked diastolic shock, due to recoil of the blood 
upon the aortic valves. When the aneurismal sac is 
filled with clotted blood the expansile impulse is absent 
and the diastolic less intense. In a certain number of 
cases a well-marked thrill may also be detected. The 

Fig. 94. 




Aneurism of aorta, bulging of sternum and pulsating tumor, 



force of the aneurismal pulsation should nearly equal 
that of the heart at the apex (Balfour). The location of 
the apex beat and the occurrence of confirmatory signs 
will vary according to the site of the tumor. 

1. Ascending Portion of the Arch. — Aneurism of 
this portion of the aorta is attended by a well-marked 
dilating impulse, accompanied with thrill, followed by 



DISEASES OF THE BLOOD-VESSELS. 



397 



diastolic shock. The apex beat is displaced downward 
and to the left, and usually increased in force. 

When the aneurism involves the innominate artery, 
the right radial pulse is usually smaller and slightly 
delayed. 

2. Transverse Portion of the Arch, — Over the sternal 
region the impulse is usually heaving in character, 

Fig. 95. 




Aneurism of aorta, bulging of sternum and pulsating tumor, 



unless absorption and perforation have occurred. 
Fingers introduced into the episternal notch may detect 
the dilatation of the aorta, expansile pulsation and thrill. 
The radial pulse generally shows marked difference in 
character. Tracheal tugging is almost diagnostic of 
aneurism of this portion of the aorta. Pressure upon 
the oesophagus causes dysphagia. 



398 



THE CIRCULATORY SYSTEM. 



3. Descending Portion of the Arch and Upper Por- 
tion of the Descending Aorta. — When the aneurism de- 
velops forward, the apex beat is displaced toward the 
right, and may be found to the right of the sternum ; 
while to the left of the sternum the aneurismal pulsation 
may be detected in the region of the normal apex. The 
aneurismal pulsation is slightly later than that of the 

Fig. 96. 




Aneurism of the ascending aorta. Pain, dullness. Pulsation, 
diastolic shock, faint bruit 



apex. When it develops posteriorly, the apex may be 
displaced to the right or left, according to the direction 
of the tumor. Impulse may be felt in the interscapular 
space. 

J/-. Descending Aorta,, Inferior Portion. — The apex 
is elevated. There is diffuse pulsation over the lower 
portion of the thorax. 

5. Abdominal Aorta. — As the artery can be grasped 



DISEASES OF THE BLOOD-VESSELS. 399 

through the abdominal wall, the dilating character of the 
pulsation is easily detected. 

Percussion. — There is diminished resonance or flat- 
ness over the site of the tumor. At times percussion 
detects the presence of aneurism when inspection and 
palpation are negative. AVlien the sac projects close to 
the surface, its size may be definitely determined. 

1. Ascending Portion of the Arch. — Aneurism pro- 
jecting forward and to the right gives well-marked dull- 
ness in the second and third interspaces. 

2. Transverse Portion of the Arch. — Aneurism 
pressing upon the sternum causes dullness over the 
upper portion of the sternum, with increased sense of 
resistance. When developing posteriorly or backward, 
increased dullness in the interscapular region may be 
detected. 

3. Descending Portion of the Arch and Upper Por- 
tion of the Descending Aorta. — Displacement of the 
heart causes percussion dullness over an abnormal site. 
Unless the aneurism projects close to the surface, it 
may be undetected by percussion. Posteriorly, increase 
in the percussion dullness may be made out in the left 
interscapular space from the third to the sixth dorsal 
vertebras. 

Ji. Descending Aorta, Inferior Portion. — The normal 
pra^cordial flatness or dullness are extended to the left 
and over the lower portion of the thorax. 

5. Abdominal Aorta. — Dullness over site of tumor. 

Auscultation. — The signs detected by auscultation 
are not as distinctive as those noted by inspection, palpa- 
tion and percussion. Frequently over the aneurism the 
first and second sounds of the heart are heard with 
abnormal clearness, and are at times the only signs 
detected. One or both of the cardiac sounds may be 
replaced by a murmur or bruit, which varies widely in 
quality. A systolic bruit is most frequently present, 
and may be made in (a) the aneurismal sac, and gener- 
ally disappears when the contents become solid by coagu- 



400 THE CIRCULATORY SYSTEM. 

lation; (b) in the dilated artery; (c) in a portion of the 
aorta partially compressed by the tumor. A systolic 
murmur may be heard over the prsecordia (Drummond's 
sign) , or detected when the chest piece of the stethoscope 
is introduced into the mouth and the lips closed on it 
(Sanson's sign). Corresponding to the diastolic shock 
felt on palpation, an intense, low-pitched second sound 
may be heard over the aorta. When heard behind in the 
interscapular space, it is especially significant of dilata- 
tion of the aorta. A diastolic murmur is heard when 
incompetency of the aortic valve is present, and replaces 
the diastolic shock and sound. The respiratory sounds 
will be altered according to the site of the aneurism and 
the pressure on the trachea and bronchi, or displacement 
of the lung. 

1. Ascending Aorta. — Usually, the systolic and 
diastolic cardiac sounds are either intensified or replaced 
by murmurs. The most frequent combination is a well- 
marked systolic bruit, and a short, sharp diastolic shock 
or sound heard over the second intercostal space to the 
right of the sternum and behind in the interscapular 
region. Pressure on the right or left bronchus gives 
rhonchi, tubular breathing (pressure type) and feeble 
vesicular murmur over the corresponding side of the 

chest. 

2. Transverse Portion of the Arch. — Cardiac sounds 
and murmurs are similar to those heard when the ascend- 
ing portion is involved. Pressure on the trachea causes 
harsh stridor to replace the normal respiratory sounds 
over both lungs. Pressure limited to the left bronchus 
gives tubular breathing at point of pressure and feeble 
vesicular murmur over the left side of the thorax. 

3. Descending Portion of the Arch and Upper Por- 
tion of Descending Aorta. — Usually distinctive changes 
in the cardiac sounds and murmurs are not present, and 
the diagnosis is made from evidences of pressure on the 
left bronchus and lung and from the displacement of the 
heart. Narrowing of the left bronchus causes stridor 



DISEASES OF THE BLOOD-VESSELS. 401 

and diminished breathing below the affected portion. 
Occlusion of the bronchus and collapse of the lung are 
attended with absence of respiratory murmur and feeble 
vocal resonance. 

J/.. The Descending Aorta, Inferior Portion. — The 
auscultatory signs are very slight. Pressure of the 
tumor does not produce stridor, but may cause over the 
lower portion of the chest, occupied by compressed lung, 
bronchial breathing; and increased vocal fremitus. 

5. Abdominal Aorta. — Usually over the site of the 
pulsation a well-marked systolic bruit is present. A 
systolic murmur over the aorta is not pathognomonic of 
aneurism, as it may occur when the aorta is relaxed, or 
displaced by anterior curvature of the spine, or slightly 
narrowed by the pressure of the stethoscope. 

Differential Diagnosis. — The distinctive signs of 
thoracic aneurism are the presence of visible pulsations, 
with or without bulging of the chest wall, and tumor. 
Over the tumor, when present, the pulsations are expan- 
sile, and frequently accompanied by systolic thrill anrj 
diastolic shock. The force of the pulsation felt should 
nearly equal that felt over the apex beat. The apex 
beat and area of cardiac dullness may be normal or dis- 
placed. Over the site of the aneurism, when it reaches 
the surface, there may be flatness, surrounded by an area 
of relative dullness. When deep seated, diminution of 
resonance only over that portion of the chest may be 
noted. Auscultation may reveal increased cardiac 
sounds, with diastolic shock or bruits replacing the 
normal sounds. In addition to the above, pressure 
signs will be present, varying in character according to 
the location of the aneurism. 

Mediastinal Tumors. — Mediastinal tumors have 
many physical signs in common with thoracic aneurism, 
especially those referable to pressure. The chief dis- 
tinguishing points are that mediastinal tumors, while 
producing bulging of the chest, are not attended with 
erosion of the bony thorax. The pulsations, when pres- 

26 



402 TEE CIRCULATORY SYSTEM. 

ent, are not expansile, but convey the impression of a 
non-expansile force being transmitted. Over the site of 
pulsation, thrill and diastolic shock are not present. 
Pressure upon the large interthoracic veins produces 
more marked superficial venous disturbance. 

Glands in the clavicular and interclavicular and axil- 
lary regions are involved when the tumor is malignant. 
Over the site of bulging there is increased firmness of 
the bony thorax to pressure. 

The superficial area of flatness is very much greater 
than that over which pulsations are felt. Diminution of 
sternal resonance is especially marked. Over the site of 
dullness, increased resistance and loss of normal thoracic 
elasticity are noticeable. 

Over the site of dullness and pulsation, distinctive 
cardio-vascular sounds are absent. Over the lung, 
pressure symptoms are more marked and uniform, and 
apt to be attended by secondary structural changes, due 
to extension of the growth from the mediastinal. 

ARTERIO-SCLEROSIS OR ARTERIO-CAPILLARY 

FIBROSIS. 

This condition causes increased peripheral resistance, 
with heightened arterial tension. 

The effects of arterio-sclerosis can be divided into 
three stages. First stage — In proportion to the inter- 
ference with the flow of blood through the capillaries and 
arteries, there is a corresponding hypertrophy of the left 
ventricle, which compensates for the lesion as long as the 
left ventricle is able to empty its contents into the aorta. 
The second stage or failure of compensation. — When 
the muscular power of the heart is insufficient to over- 
come the resistance in the aorta, dilatation of the ven- 
tricle occurs, with insufficiency of the mitral valves 
(mitral regurgitation), and the subsequent changes in 
the pulmonary circulation, and compensating hyper- 
trophy of the right heart. Subsequently (third stage) 



DISEASES OF THE BLOOD-VESSELS. 403 

failure of the right ventricle to overcome interference 
with the pulmonary circulation may induce dilatation 
of the right ventricle, tricuspid regurgitation and inter- 
ference with venous return. 

Physical Signs. — The cardiac changes of arterio- 
sclerosis are identical with those that occur when the 
interference is due to obstruction at the aortic orifice. 
In arterio-sclerosis the obstruction is simply transferred 
from the area of the aortic valves to a more distant point 
in the arterial system. (See Aortic Stenosis.) 

The superficial blood-vessels are lengthened, promi- 
nent and tortuous, and the pulsations are visible. On 
palpation the artery is hard and incompressible, and 
even when the pulsations are obliterated can be felt be- 
yond the point of compression as a hard, rounded cord. 
On auscultation, the aortic second sound differs from 
that of aortic stenosis, in that it is accentuated and ring- 
ing in quality. With failure of compensation at the 
left ventricle or regurgitation at the mitral orifice, the 
aortic second sound becomes indistinct. 



PAET IV. 



THE ABDOMINAL OBGANS. 



CHAPTEE XV. 

INSPECTION. 

Inspection of the abdomen includes consideration of 
the shape and size of the abdomen, the changes in tho 
skin, the condition of the blood-vessels, both arterial and 
venous, and the movements, both respiratory and vis- 
ceral. The examination should be made with the patient 
in both the erect and recumbent postures when possible, 
although usuallv it is made in the recumbent position 
only. In the standing posture the shape of the abdomen 
and the support given the abdominal viscera by the 
parietes are most clearly seen, and in enteroptosis this 
method of examination is especially valuable. Exami- 
nation in the recumbent posture demands that the body 
shall be exposed from just below the mammary glands 
as far as the pubes, so as to compare the lower portion 
of the thorax with the abdomen. The patient should 
lie perfectly straight on the back, the head and trunk 
slightly elevated, so as to relax the abdominal muscles. 
The abdomen should be well illuminated, and the ex- 
aminer should view it from all sides, so as to note any 
inequalities of surface and shadows caused by move- 
ments. The amount of information gained by inspec- 
tion of the abdomen depends on the care exercised by the 
examiner in having his patient in a proper position, the 



406 THE ABDOMINAL ORGAN 8. 

arrangement of the light so that it can be varied both in 
intensity and angle, and methodically noting all the 
changes that occur. 

The Normal Abdomen. — The contour of the abdomen 
should bear a definite relation to that of the thorax and 
general physique of the patient. In children and in the 
adult male past middle life the abdomen is relatively 
larger and rounder, especially in the upper and middle 
zones. In males during early adult life there is gener- 
ally a depression in the epigastric region. In females, 
independent of the effects of tight lacing, there is more 
or less of a depression in the lower portion of the 
thorax and hypochondriac regions, with a lengthening of 
the waist line and a corresponding broadening of the 
lower portion of the abdomen. When compression of the 
thorax by corsets has occurred, this natural condition is 
made more marked. In those who have borne children, 
the lower portion of the abdomen is larger and the walls 
are flaccid. 

Examination of the Parietes. — The skin may show cer- 
tain discolorations (jaundice, pigmentation of Addison's 
disease and that secondary to pregnancy) or striae (linea 
albicantes), the result of overdistension (pregnancy, 
ascites, obesity). It may be tense, dependent upon dis- 
tension of the abdomen, or lax, secondary to overdis- 
tension from pregnancy, ascites, tumors, and in wast- 
ing diseases. 

The blood-vessels may be more prominent than nor- 
mal, especially the veins, when the superficial ones are 
enlarged on account of compensatory changes due to 
obstruction of return circulation, either portal or 
general. 

The movements of the abdomen are (a) respiratory. 
These are especially marked in the adult male and in 
children. With inspiration the abdomen becomes promi- 
nent, especially in the upper zone. In females this is 
less marked, on account of the breathing being largely 
costal. With deep respiration the movements are more 



INSPECTION. 407 

pronounced in both sexes. Increased respiratory move- 
ment occurs in diseases that interfere with expansion of 
the upper portion of the thorax. Diminished respira- 
tory movement occurs in all painful affections below the 
diaphragm, either involving the abdominal muscles or 
the peritoneum, general or local, and especially that por- 
tion covering the organs that are influenced by the 
descent of the diaphragm, (b) Vascular. — These are 
seen in the median line between the ensiform and the 
umbilicus, and may be caused by pulsations of (a) 
normal aorta in thin persons with flaccid abdominal 
walls; (b) relaxed aorta in nervous and neurasthenic 
individuals. It is especially marked in some women 
at the menopause, and is mistaken for aneurism; (c) 
aneurism of abdominal aorta or its branches; (d) 
growths or tumors resting on the aorta and transmitting 
its pulsations ; (d) pulsations of the liver secondary to 
valvular diseases of the heart. 

(c) Visceral. — Peristalsis of the normal stomach is 
not noticed except when the abdominal walls are thin 
and relaxed. These movements may be noted when the 
stomach is distended and the peristalsis become exag- 
gerated, especially when there is stenosis at the pylorus, 
with secondary hypertrophy of the walls. 

The movements of the stomach are seen as distinct 
waves, passing from left to right across the epigastric 
region to the costal margin on the right side. When 
more pronounced, they may cause protuberances or 
bosses of the abdominal walls, which pass slowly in- the 
same direction. The latter conditions occur when the 
stomach is markedly dilated, and may at times be seen 
over a large portion of the abdomen. 

Movements of the small intestine may normally be 
seen when the abdominal walls are thin and lax. Those 
of the large intestine are seen only in pathological con- 
ditions, dependent upon neuroses or stenosis, with over- 
distension of the gut above the site of obstruction. 
Those of the small intestine are vermicular, and are 



408 



TBE ABDOMINAL ORGANS. 



seen especially in the umbilical region. Those of the 
large intestine are especially marked in the lumbar and 
epigastric regions, and the direction of the motion is 
contrary to that of the stomach, being from right to left. 
Enlargement of the Abdomen. — Enlargement of the 
abdomen may be (A) symmetrical, (B) localized. 



Fig. 97. 



Fig. 98. 





Ascites due to cirrhosis of liver. 



Symmetrical enlargement of the abdomen may be due to 

(1) increase of the abdominal walls (fat, oedema, etc.). 

(2) Distension of the peritoneal cavity by air (rare) or 
fluid (ascites). (3) Distension of the intestine with gas 
(tympanites). (4) Massive tumor filling the abdominal 
cavity (uterus: pregnancy, fibroids; ovaries: distended 
bladder, etc.). Although these conditions may cause uni- 



INSPECTION. 409 

form enlargement of the abdomen, certain peculiarities 
noted by inspection are aids in differential diagnosis. 
Enlargement due to increase in the abdominal walls is 
associated with general obesity. The walls in the recum- 
bent posture are more or less widened, and lack the 
dome-shaped appearance. In ascites the fluid collects in 
the most dependent portion of the abdomen, which en- 
larges laterally, and its shape changes as the patient is 
turned on the side or sits up. (Figs. 97 and 98.) In 
accumulations of gas in the intestine, the abdomen is dis- 
tended in all directions uniformly, and there is no 
change in shape with altered posture of the patient. In 
tumors the enlargement is not entirely symmetrical. 

Local Abdominal Enlargement or Bulging. — Inspec- 
tion is very important in detecting local enlargements or 
bulffinffs. The abdomen should be viewed from all 
directions, in order to detect the shadows caused by un- 
evenness of its surface. Local enlargements of the 
abdomen may be caused by enlargement of structures 
normally situated in that region or tumors springing 
from them, or the region may be invaded by organs dis- 
placed from adjacent areas. 

Epigastric Region. (1) Abdominal ~\Yalh. — Local 
contractions of the recti (phantom tumor) ; abscess of 
abdominal walls, lipomas. 

(2) Peritoneum. — Localized effusions into the lesser 
peritoneal cavity, tumors of the omentum. 

(3) Stomach. — Distension from food or gas, or dila- 
tation, with or without stenosis ; tumors of that portion 
of the stomach that is parietal (cancer, etc.). 

(Jf) Pancreas. — Cysts, cancer. 

(5) Aorta. — Aneurism of the aorta or its branches. 

(6 ) Liver. — Enlargements of the liver, displacement 
of the left lobe of the liver downwards, abscess, hydatid, 
gumma, cancer, etc. 

(7) Large Intestine. — Distension of transverse colon, 
tumor of colon. 

Umbilical Region. — Many of the conditions that were 
noted in the epigastrium may extend to this region also. 



410 THE ABDOMINAL ORGANS. 

(1) Abdominal Wall. — Umbilical hernia, abscess, 
lipoma. 

(2) Peritoneum. — Encysted effusion into the peri- 
toneal cavity, tumors of the omentum. 

(3) Stomach. — Dilatation, tumors of the pylorus. 
(Ji-) Aorta. — Pulsations of aorta due to aneurism or 

anterior curvature of the spine. 

(5) Enlarged Mesenteric or Retro-peritoneal Glands. 
— Tubercular, cancerous, etc. 

(6) Intestine. — Cancer of the intestine, especially the 
large intestine. 

(7) Movable liver; spleen J kidneys may project into 
this region. 

Hypogastric Region. — Distensions may be caused other- 
wise than by changes in the abdominal wall and peri- 
toneum ; they are dependent chiefly upon distended blad- 
der and enlarged uterus (pregnancy, tumors). 

Upper Right Lateral Region. — In the lateral region 
(including the hypochondrium and upper portion of the 
lumbar region to the level of the umbilicus) enlarge- 
ments due to changes in the abdominal walls and perito- 
neum are rare. 

(1) Liver. — Enlargements of liver (fatty liver, 
abscess, congestion, syphilis, hypertrophic cirrhosis, 
amyloid, displacement of the liver downward, leukaemia, 
hydatid, carcinoma). 

(2) Gall Bladder. — Distended gall bladder, gall 
stones, hydrops and cancer. 

(3) Ascending Colon. — Distension by gas and impac- 
tion of faeces, cancer. 

(Jf) jKtcZwey.— -Hydronephrosis, pyonephrosis, hsemo- 
nephrosis, sarcoma, perinephritic abscess, cancer of 
suprarenals. 

Upper Left Lateral Region. — (1) Stomach. — Dilated, 
distended, carcinoma of fundus. 

(2) Spleen. — Enlargements, congestion, primary or 
secondary, to obstructive disease of liver; leukaemia, 



INSPECTION. 411 

pseudo-leukaemia, malaria, movable or displaced spleen, 
abscess, carcinoma, hydatid. 

(3) Intestine. — Distension by gas and impaction of 
faeces in splenic flexure of colon. 

(4.) Kidneys. — Enlargements same as on right side. 

Lower Right Lateral Region. — (From the level of the 
umbilicus to the brim of the pelvis.) 

(1) Abdominal Wall. — Hernia, abscess of abdominal 
wall and psoas abscess burrowing forward. 

(2) Peritoneum. — Localized tumor secondary to dis- 
ease of appendix or intestine. 

(3) Intestine. — Tumors of appendix, impacted faeces, 
typhlitis, perityphlitis, intussception, cancer of ca?cum, 
or of ascending colon. 

(J/.) Kidney. — Displaced kidney; tumors of kidneys 
extending into this region. 

(5) Ovaries and Tubes. — Ovarian tumors, cysts of 
the broad ligament, pelvic abscess, tubal or extra-uterine 
pregnancy. 

Lower Left Lateral Region. — Distension of the sigmoid 
flexure of the colon due to impaction of fauces, new 
growths in rectum, in addition to the same conditions, 
may occur on the right side. 

Decrease in Size. — The abdomen may be decreased in 
size, due to contraction of the abdominal muscles, as 
occurs in the early stage of peritonitis and secondary to 
cerebral disturbance, especially basilar meningitis. In 
stenosis of the oesophagus or cardiac portion of the 
stomach, the empty condition of the stomach and intes- 
tines, with the emaciation, causes the abdomen to have a 
lax, shrunken appearance. 

Illumination of the Stomach. — The outline of the stom- 
ach may be seen by the use of Einhorn's gastro-diaphane. 
For this purpose the stomach is first washed out, and 
then filled with clear water, into which an electric bulb 
attached to a flexible wire is introduced. 



CHAPTEE XVI. 

PALPATION. 

Method of Examination. — For satisfactory palpation 
of the abdomen, it is necessary for the patient to be in 
the recumbent posture, and the regions of the abdomen 
should be accessible from all sides. The head and 
shoulders should be elevated so as to relax the abdominal 
muscles, and the patient nrust be instructed to be as limp 
as possible, and not try to aid the examination by any 
voluntary motion. As the object of the examination is 
to reach the abdominal organs, relaxation of the abdo- 
men is a necessity. Very little is gained by having the 
patient draw up the legs, as there is a tendency to hold 
the abdominal muscles rigid in order to support them. 
When the patient is very nervous or apprehensive of 
the examination, it may be necessary to divert the atten- 
tion by asking questions and seemingly to examine the 
tongue with the eye, while with the hands we are pal- 
pating the abdomen. The hands of the examiner should 
be warm, to avoid causing reflex contraction of the 
abdominal muscles. 

At the beginning of the examination the palms of the 
hands should be placed lightly upon the abdomen and 
passed over it in all directions, so as to get a general idea 
of the condition of the walls and the degree of resistance. 

Patients who are very ticklish are frequently more 
disturbed by a light touch than by more forcible palpa- 
tion. The amount of pressure should be gradually in- 
creased, in order to determine whether any part of the 
abdomen is sensitive, as shown by pain and local muscu- 
lar contraction. Whenever such areas are present, their 
examination should be left till the last. 



PALPATION. 413 

In general enlargement of the abdomen it is necessary 
to determine its resistance (gas, fluid or solid). 
When local enlargements are detected, to determine (1) 
their relation to the surface, (2) whether they are fixed 
or movable, the extent and direction of their mobility, 
and whether they move with respiration; (3) their 
shape and size, nature of their surface; (4) their rela- 
tion to structures normally found in that region and to 
adjacent organs; (5) the presence of frictions, thrills 
and pulsations; (6) whether they are sensitive or not. 

In order to gain more definite knowledge, it is often 
necessary after examination in the recumbent posture 
to put the patient in the lateral or in the knee-chest 
position. 

Abdominal Walls. — The condition of the abdominal 
walls affects the information obtained by palpation 
regarding the abdominal viscera. 

When the walls are thin and relaxed, they offer very 
little obstacle to palpation. Rigidity of the walls, due 
to muscular contraction, prevents satisfactory palpation, 
so that an anaesthetic may be required. Localized con- 
tractions, especially of the recti, due to ticklishness, pain 
or tenderness, frequently simulate tumors of the wall 
or underlying structures. 

Increase in thickness of the abdominal walls from fat 
renders palpation very difficult. 

Local enlargements and tumors of the abdominal wall 
may be due to (a) muscular contractions, (b) fatty 
tumors (lipomas), (c) abscess, (d) hernia. All these 
tumors give the impression of being superficial. They 
can be grasped by the hand, and their mobility is limited 
to that of the walls, while tumors situated within the 
cavity do not have their mobility limited to the walls 
unless they adhere to the parietal peritoneum. 

Tumors due to muscular contraction vary in shape 
and size. Contraction of the recti causes a well-defined 
oblong mass, with the long axis corresponding to that of 
the muscles, while those of the oblique muscles are ill- 



414 TEE ABDOMINAL ORGANS. 

defined. The characteristic feature of muscular tumors 
is their variable consistency; at one time they are hard 
and resistant, and as the muscle relaxes they become 
softer, smoother and finally disappear (phantom 
tumor) . They may be painful when due to rheumatism 
or neuralgia, or attended with irritation of the parietal 
peritoneum. 

Lipomas are soft, yielding masses with fairly well- 
defined borders, and with greater or less mobility under 
the skin. Their firmness is increased when the surface 
over them is chilled by either spray or the application 
of salt and ice. They are painless, and when grasped 
firmly and forced to the surface the skin over them 
shows depressions, indicative of the lobulated structure 
of the tumor. 

Abscesses are usually tense and elastic or fluctuating * 
they are well defined unless surrounded by oedematous 
tissue, which gives a boggy feel and pits on pressure. 
Acute abscesses are red and painful, with local elevation 
of temperature. 

Hernias. The usual site of the hernial tumor is at 
the natural openings in the abdominal walls and the 
umbilicus, although they may occur at any part of the 
abdominal parietes. The mass gives an air-cushion feel, 
and becomes more tense as the intra-abdominal pressure 
is raised by deep breathing, coughing or contraction of 
the abdominal muscles. They are not usually tender, 
and firm pressure may reduce the mass with sensation of 
gurgling. After reduction, the opening in the abdomi- 
nal wall can be felt. Percussion over the mass gives a 
tympanitic note. 

Separation of the recti muscles leads to projection of 
the abdominal wall. The tumor is soft, yielding, with 
air-cushion feel and tympanitic note. 

Peritonium. — ^Normally, the peritoneum presents no 
palpable phenomena. Acute general inflammation 
causes the abdomen to become extremely tender and 
resistant, on account of muscular contraction. Later 



PALPATION. 415 

paralysis of the intestine causes tympanites to be 
marked. Respiratory movements are diminished or 
absent. 

General peritonitis may be simulated by painful 
affections of the abdominal walls (rheumatism, neural- 
gia, lead colic, etc.) and tympanites, due to intestinal 
disease, or to hysterical conditions. In painful affec- 
tions of the abdominal wall, respirations are not dis- 
turbed to the same degree as in peritonitis. Pain is 
more paroxysmal, and the constitutional symptoms are 
less severe. In hysterical conditions the physical signs 
may be identical. The diagnosis is made by considera- 
tion of all symptoms', especially others of an hysterical 
nature. 

Acute localized peritonitis is usually secondary to dis- 
ease of organs covered by the serous membrane, and will 
be considered with each organ. 

Diffuse thickening of the peritoneum secondary to 
acute or tubercular involvement gives an increased sense 
of resistance, and a more or less boggy feel. In local 
thickenings and ill-defined indurations there are felt 
nodular masses, more or less movable, simulating en- 
larged glands. They are frequently associated with 
thickening and retraction of the omentum (q. v.). 

Fluid in the Peritoneal Cavity, Ascites. — Fluid 
causes a change in the normal feel of the abdomen, and 
abnormal sensations. The fluid collects in the most de- 
pendent portion of the sac, according to the posture of 
the patient; and as it increases the intestines are dis- 
placed, floating on its surface unless prevented by peri- 
toneal adhesions or short mesentery. Over the fluid the 
normal air-cushion feel of the abdomen is replaced by 
increased resistance, as if the wall were thickened. 
This is especially noticeable in the flanks with the 
patient in the recumbent posture. Above the fluid the 
distension of the abdomen causes the walls to be tense, 
otherwise the feel is normal. With change in posture of 
the patient, there is corresponding shifting of the fluid 
and intestines. 



416 THE ABDOMINAL ORGANS. 

Fluctuation. — When the palm of the hand is placed 
on one side of the abdomen near the level of the fluid, 
while on the opposite side a sharp percussion tap is made 
with the other hand, a wave-like motion in the fluid is 
felt as a distinct impulse, most distinct near the level of 
the fluid when the fluid is under tension and able to 
move freely. Under such conditions a light tap is suffi- 
cient to produce the phenomenon. When the abdominal 
wall is thick and the amount of fluid scanty, or if it is 
prevented from moving freely, the stroke must be 
stronger, and the impulse is feeble. It is often difficult 
to determine whether the impulse felt has been trans- 
mitted by the fluid or by the abdominal wall. Transmis- 
sion by the abdominal wall can be arrested if an assistant 
presses firmly with the ulnar edge of the hand in the 
median line. When the amount of fluid is small, 
fluctuation may be best detected by placing the patient 
on the side and placing a hand over the flank behind, 
between the lower ribs and the crest of the ilium, and 
tapping over the front of the abdomen. Fluctuation 
may be absent when the abdomen is overdistended and 
tension is very high, or when adhesion of the intestines 
or a short mesentery prevents the usual motion of the 
fluid. 

The abdomen in ascites is usually painless, unless the 
condition is secondary to acute peritonitis or complicated 
by it. Palpation of solid organs and tumors is prevented 
when the amount of fluid is large. By dipping (i. e.. 
punching sharply with the tips of the fingers) over the 
organs sought for, the fluid is displaced, and the surface 
or edge of the solid organs can be felt. 

Fluid in the peritoneal cavity may be due (a) to 
inflammation of the peritoneum, simple, tubercular or 
cancerous; (b) interference with portal circulation 
(obstructive disease of the liver (q. v.), thrombosis of 
the portal vein, pressure on the portal vein from abdom- 
inal tumors, etc.) ; (c) interference with the general 
return circulation secondary to pulmonary and cardiac 



PALPATION. 417 

disease ; (d) as a part of general dropsy (kidney disease, 
anaemic condition). 

The differential diagnosis of the cause is made by the 
physical signs of the primary lesion. Frequently the 
condition of the liver can only be determined after 
tapping. 

A localized collection of fluid may occur in any por- 
tion of the peritoneal sac. It is most common in the 
lesser peritoneal cavity, where it forms a tense, globular, 
cyst-like tumor in the epigastric region, not movable, 
and over which distinct fluctuation cannot be obtained. 
It is generally painless. At times it may transmit from 
the aorta pulsations which are not expansile. 

Air in the peritoneal cavity, due to perforative peri- 
tonitis, gives marked distension of the abdomen, with 
increased tension of its walls. The diagnosis from 
tympanites is made by percussion and auscultation. 

The Omentum is not palpable unless thickened by in- 
flammation or new growths. Deposits of fat in the 
omentum (peritoneal lipoma) give a thickened, elastic 
feel to the abdomen, with the impression of fluctuation. 
Thickening of the omentum may occur from chronic or 
tubercular peritonitis, and gives the sensation of 
increased superficial resistance over the upper zone of 
the abdomen, without any free border being detected. 
There may be tenderness in the acute and subacute 
stages, when more chronic there is no pain. The mass 
is not movable with respiration. Ketraction of the 
thickened omentum mav form a distinct tumor in the 
upper portion of the abdomen. The tumor may be felt 
as a transverse ridge with a distinct border below, which 
may simulate an enlarged left lobe of the liver, or it may 
be an irregular or ball-like mass. Cancer nodules mav 
be diffused over the omentum, or new growths may form 
irregular masses similar to those in the stomach and 
liver. Tumors of the omentum do not move with 
respiration unless attached to the edge of the liver, in 
which case differential diagnosis is very difficult. They 

37 



418 TEE ABDOMINAL ORGANS. 

are differentiated from primary malignant growths of 
the stomach by being fixed, and more prominent when 
the stomach is full or inflated. 

Hydatid cysts of the omentum are rare. When 
unilocular, they give a sensation of superficial, globular 
tumors, and the hydatid thrill may be present. Multi- 
locular cysts, when small, may simulate the early stage 
of cancerous infiltration. 

Stomach. — Normally, the stomach cannot be detected 
by palpation, as only a small portion of the anterior sur- 
face and greater curvature is in contact with the abdom- 
inal wall. In extreme emaciation, during contraction 
of the stomach, there is slight resistance. Normally, in 
most persons the upper portion of the epigastrium is 
more sensitive to pressure than the rest of the abdomen. 
Increased tenderness OA T er the gastric region occurs in 
acute and chronic catarrhal inflammation of the stom- 
ach ; in malignant disease, in ulcer (circumscribed area) 
and whenever the peritoneal covering of the stomach is 
involved secondary to gastric disease. 

In dilated or displaced stomach the boundaries can- 
not be determined by palpation. The swelling noted 
by inspection gives a soft, yielding feel, except during 
contraction, when the sensation varies according to the! 
cause of the dilatation. In atonic dilatation there is 
slight increase of resistance, and an even, wave-like 
motion from left to right can be detected. When dilata- 
tion is due to obstruction at the pyloris (cancer, ulcer, 
stenosis from adhesion, or displacement) there is hyper- 
trophy of the muscular coat, and the contractions of the 
stomach cause hard masses and irregular protuberances 
to be felt as the peristaltic wave passes across the abdo- 
men. Over the region of the pyloris the contraction is 
harder and longer, and almost always accompanied with 
sensations of gurgling or escape of gas.. It is only excep- 
tionally that the normal pylorus can be felt as a tumor. 
Splashing and succussion sounds (clapotage) can be ob- 
tained in a dilated stomach when it contains both gas and 



PALPATION. 419 

fluid. They are obtained by placing the tips of the 
fingers over the stomach and shaking it with quick 
movements, or by bimanual palpation, one hand beneath 
the ribs behind and the other over the stomach in front. 
Thev are diagnostic of dilatation onlv when taken in 
connection with other signs, as they can be obtained in 
the normal stomach, and in the colon when the contents 
are liquid. 

Tumors of the Stomach. — Tumors of the stomach 
can only be felt when situated in that portion which is 
in contact, normally or abnormally, with the abdominal 
walls. They may be due (1) to contracted stomach, (2) 
diffuse infiltration of the walls by cancer; (3) local 
thickenings of different portions of the stomach wall 
by inflammatory products or new growths. 

The entire stomach may be so contracted as to form a 
tumor (a) in stenosis of the oesophagus or cardia, (b) by 
the prolonged use of concentrated diet, (c) by fibrous 
thickening of the stomach, with or without cancerous 
infiltration. In these conditions the stomach is usuallv 
a rigid mass, felt as a transverse ridge in the region of 
the normal stomach, and giving much the same sensation 
as a thickened omentum. It is movable, and changes its 
position with deep breathing. 

Diffuse infiltration of the stomach wall may be later 
associated with contraction of the stomach and formation 
of a tumor, as mentioned above, or the lumen of the 
viscus may be increased. In the latter condition the 
stomach is felt as a large, ill-defined mass, which, during 
contraction, becomes harder and has the more definite 
contour of the stomach. It may occupy the normal 
gastric position, but is usually displaced downward, and 
the pylorus is felt somewhat to the left of the median 
line. 

Tumors of the Pyloric Region. — These may be 
due (1) to primary changes at the pylorus, as already 
mentioned, or to extension of cancerous growths from 
neighboring organs to this region. 



420 THE ABDOMINAL ORGANS. 

The characteristic features of primary tumor of the 
pylorus are (a) their location ; usually they are detected 
to the right of the median line, between the umbilicus 
and the ensiform cartilage. When stenosis is marked, 
dilatation and displacement of the stomach cause the 
tumor to be felt in the region of or below the umbilicus 
and to the left of the median line. (b) Mobility. 
When felt in the epigastric region, the tumor is movable 
in all directions, but more freely downward and to the 
left. When the pylorus is displaced below the umbili- 
cus, the mobility is not so great, (c) The tumors vary 
in size, and are usually actually larger than palpation 
would indicate, (d) Their consistency is hard ; during 
peristalsis they become harder, and their contour more 
defined, (e) The detection of gurgling or escape of gas 
is an important diagnostic sign, especially when it occurs 
during peristalsis. 

Tumors of the pylorus, due to extension from neigh- 
boring organs, lack the characteristic mobility, and are 
usually associated with the physical signs of the primary 
growth. 

Pancreas. — The normal pancreas is not easily palpable, 
although claim has been made that in extremely thin 
persons and in those with enteroptosis it can be dis- 
tinctly felt. In diseased conditions the gland can only 
be detected when it is enlarged to a considerable degree. 
In acute or chronic pancreatitis it is not palpable, but in 
the epigastric region tenderness on firm pressure may be 
present with increased resistance, giving the sensation 
of an ill-defined tumor. 

Pancreatic enlargements are mostly due to cancer and 
cysts. Tumors due to tubercle, gumma, lymphoma and 
sarcoma are rare, and when present give most of the 
physical signs of cancer. 

Cancer of the Pancreas. — As this usually begins 
at the head of the gland, a tumor is felt in the epigas- 
trium, midway between the xiphoid cartilage and the 
umbilicus, and a little to the right of the median line, 



PALPATION. 421 

close to the edge of the liver. Its form may be round or 
oblong, but the outline cannot be well denned. Its posi- 
tion is not influenced by respiratory movements. When 
it can be easily felt, it is generally fixed, or only slightly 
movable. Non-expansile pulsations may be felt, due to 
its relation to the aorta. Compression by the tumor of 
the portal vein causes ascites; that of the vena cava 
causes oedema of the lower extremities. The presence 
of a tumor in the region of the pancreas is not sufficient 
for diagnosis of cancer of that organ, as similar tumors 
may be caused by cancer of the pylorus, duodenum, 
colon, or liver. The associated signs of cancer of the 
pancreas are (1) early, intense and persistent jaundice; 
(2) dilatation of the gall bladder, (3) enlargement of 
the liver, (4) fatty stools. 

Differential Diagnosis. — It is differentiated from 
tumor of the pylorus by being deeper seated and not 
movable, and that the stomach is not dilated and hyper- 
trophied. When the growth extends to the duodenum, 
stomach changes may be present. Tumors due to cancer 
of the lower edge of the liver, in the region of the pan- 
creas, move with respiration, and their relation to the 
edge of the liver can usually be determined. In primary 
cancer of the gall bladder the distended gall bladder is 
harder, while the liver is not enlarged. Enlargement of 
the retroperitoneal glands from any cause may give a 
tumor similar, as far as palpation is concerned, to cancer 
of the pancreas. 

Cysts of the Pancreas. — When small, the tumor 
is felt to the left of the median line, toward the costa] 
cartilage. It is globular, smooth, resistant and inelastic, 
and when deep seated gives a sensation of hardness. It 
is uninfluenced by respiratory movements, and on firm 
pressure may be slightly movable, both vertically and 
laterally. As the cyst enlarges, it is more in the median 
line, and displaces the stomach upward (rarely down- 
ward). The transverse colon either overlies it or is 
pushed downward. It may attain to such a size as to 



422 THE ABDOMINAL ORGANS. 

fill the entire abdominal cavity, with compression of the 
bile dncts (jaundice), of the portal veins (ascites) and 
of the vena cava (oedema of the lower extremities). 
Pulsations over the tumor are frequently very pro- 
nounced, and, although they are transmitted from the 
aorta, may give a slight expansile sensation, and on aus- 
cultation often a bruit. Examination of the patient on 
the hands and knees removes these features, suggestive 
of abdominal aneurism. 

• Differential Diagnosis. — Cysts of the pancreas cannot 
by physical signs be differentiated from effusion or 
hemorrhage into the lesser cavity of the peritoneum. 
Hydatid cysts of the liver, spleen or peritoneum may 
closely resemble cysts of the pancreas. They are some- 
what more movable and elastic, and frequently give 
fluctuation or hydatid thrill. Aspiration and examina- 
tion of the fluid chemicallv, showing it to be non- 
albuminous, and microscopical evidence of hooklets de- 
termines their nature. Ovarian cyst may give similar 
signs on external palpation. Vaginal (bimanual) ex- 
amination, however, shows its relation to the pelvic 
organs. 

In hydronephrosis the most prominent portion of the 
abdomen is usually situated to the right or left of the 
median line. The lower portion of the tumor extends to 
the brim of the pelvis. It is oblong, and the colou 
usually crosses its long axis toward its inner side and not 
transversely, as in pancreatic cysts. 

Liver. — Normally, with abdominal walls of ordinary 
thickness, the liver cannot be felt at the lower border 
of the ribs, except where the left lobe crosses the epi- 
gastrium. In persons with very lax walls, and espe- 
cially in women who have borne children, the liver may 
be felt in the right mammary line at or a little below the 
free border of the ribs. In children the relatively large 
size of the liver renders it more palpable. 

In palpation of the liver attention is paid to the fol- 
lowing: (1) Position of the lower margin and thq 



PALPATION. 423 

degree to which it extends below the free border of the 
ribs, and in the epigastric region. (2) Its consistency. 
(3) The condition of its surface, whether even or un- 
even. (4) Its edge, whether sharp, rounded or irregu- 
lar. (5) Presence of pain or tenderness. (6) To what 
extent the change in the liver has involved other abdom- 
inal organs, especially the occurrence of jaundice, ascites 
and enlargement of the spleen. The diagnosis of the 
nature of the changes occurring in the liver depends 
largely upon the relative preponderance of these physi- 
cal signs. 

The edge of the liver may be felt below its normal 
area, on account (A) of displacement without increased 
size; (B) of enlargement of the liver, either uniform or 

irregular. 

(A) Displacement of the liver may be due (1) to 
interthoracic conditions which depress the diaphragm, 
and with it the liver, as enlargement of the lungs from 
emphysema, asthma, pneumonia and tumors of the lung. 
Effusion into the right pleural cavity, pneumothorax, 
mediastinal growths, pericardial effusions, cardiac 
hypertrophy and dilatation, also effusions into the left 
pleural cavity, may cause localized displacement of the 
left lobe without any marked change in position of _ the 
right. (2) Sub-diaphragmatic conditions, as collections 
of fluid or pus between the diaphragm and liver. (3) 
Prolapsus of the liver from tight lacing, enteroptosis 
and deformities dependent upon rickets and spinal 

caries. 

The degree of displacement will depend upon the 
casual factors ; the shape, size, consistency and conditio!) 
of edge and surface are usually normal unless enlarge- 
ment of the liver is a complication. In prolapsus of the 
liver, in addition to the ordinary respiratory movements, 
there is an independent mobility, due to the loose attach 
ment of the organ. 

Differential diagnosis between displacement of the 
liver without enlargement and true enlargement of tiw 
viscus is made by the percussion outline. 



424 THE ABDOMINAL ORGANS. 

(B) I. Uniform Enlargements of the liver may be 
due (1) to circulatory changes which may be active, as 
occur in hot climates and in acute inflammatory condi- 
tions, and those dependent upon infectious diseases 
(malaria, typhoid and scarlet fevers, measles, yellow 
fever, small-pox, etc.) ; passive congestion dependent 
upon interference with circulation in the hepatic vein, 
due to cardiac or obstructive pulmonary diseases or 
pressure on the vena cava. (2) Blood diseases. 
Leukaemia,' Hodgkin's disease, and pernicious anaemia. 
(3) Degenerations of the liver (fatty liver, amyloid 
liver, hypertrophic cirrhosis, diffuse syphilitic hepa- 
titis). (4) Obstructive disease of the bile ducts (jaun- 
dice), either primary or secondary. 

II. Irregular Enlargements or Tumors oe the 
Liver due to cancer, hydatid and abscess, also 
syphilitic liver. These conditions may produce uniform 
enlargements. At times irregular enlargement of the 
liver may be due to prolongation of the lower portion of 
the organ and from the effects of pressure of tight lacing. 

(1) Congestions of the liver. In simple, active 
hypersemia of the liver the enlargement is slight. The 
lower border is felt just below the free edge of the ribs 
and slightly lower than normal in the epigastric region. 
The consistency is slightly increased, the surface is 
smooth and the edge well defined. In acute infectious 
diseases, especially typhoid fever in the early stage, the 
enlargement is identical with that of simple congestion, 
later changes in the liver cause it to become larger, 
softer, and the lower margin cannot be so readily felt. 
In other infectious diseases the liver shows varying de- 
grees of enlargement and consistency, but the normal 
shape remains. Tenderness is present whenever the 
peritoneal covering is stretched or inflamed. 

In passive congestion of the liver the enlargement is 
in proportion to the amount of interference with the 
circulation. Secondary changes cause the organ to 
become harder; the surface is smooth, the edges sharp 



Dim 



Simple 

Atrophi 
liver 

Atrophi 

Syphilit 
(atrop 
rare). 

Acute y 
phy. 



rer. 



Al 



Amyloi 

Fatty li 

Adhesh 
phleb 



the 



the 



Ni 



TABLE FOR DIAGNOSIS OF DISEASES OF THE LIVER.— LEUBE. 



SIZE OF LIVER. 




CONSISTENCY OP LIVER. 




Diminished. 


Increased. 


Soft to 
Fluctuating. 


Firm, a little 

harder than 

normal 


Hard. 


Smooth to sharp. 


Simple Atrophy. 


Liver abscess. 


Fatty liver. 


Simple atro- 


Engorged. 


Fatty liver, elas- 


Atrophic nutmeg 


Diabetes liver. 


Abscess. 


phy. 


Cirrhosis. 


tic, thrill. 


liver. 

Atrophic cirrhosis 

Syphilitic liver 
(atrophic form, 


Congestion. 

Jaundice, ob- 
structive. 

Fatty liver. 


Echinococcus 
unilocularis. 


Jaundice. 
Hyperaemia. 


Syphilitic liver. 

Echi noc occ us 
multilocularis 
(becoming soft). 


Jaundice, ob- 
structive. 

Hypertrophic cir- 
rhosis (some- 
times slightly 


rare). 

Acute yellow atro- 
phy. 


Passive hyper- 
emia. 






Amyloid. 
Carcinoma. 


rounded). 
Echinococcus. 




Syphilitic liver. 






Hypertrophic cir- 


Simple atrophy. 




Leukaemia. 






rhosis. 






Hypertrophic cir- 












rhosis. 












Amyloid. 












Carcinoma. 




. 








Echinococcus. 











EDGE OP LIVER. 



Thick, 
Rounded. 



Fatty liver. 
Congestion. 
Amyloid. 



Nodular. 



Cirrhosis (rarely 
palpable). 

Abscess. 

Carcinoma. 

Syphilitic liver. 

Tubercle bacilli. 



SURFACE OF LIVER. 



Smooth. 



Congestion. 

Fatty liver. 

Jaundice, ob- 
structive. 

Elephantiasis. 

Amyloid. 

Leukaemia. 

Diabetes liver. 

Acute yellow 
atrophy. 



Nodular. 



Cirrhosis. 
Abscess. 
Syphilitic liver. 
Carcinoma. 
Echinococcus. 





JAUNDICE. 






ASCITES. 






ENLARGEMENT OF THE SPLEEN. 


Absent. 


Rare. 


Frequent. 


Absent. 


Present. 


Pain Present. 


Absent. 


Present. 


Amyloid. 

Patty liver. 

Adhesive pyle- 
phlebitis. 


(Only when the 
biliary pas- 
sages are di- 
rectly involved 
in the diseased 
processes). 

Echinococcus. 

Syphilitic liver. 


Abscess. 

Congestion. 

Cirrhosis. 

Carcinoma. 

Echinoeoccus 
multilocularis 

Elephantiasis 

Jaundice, ob- 
structive 


Fatty liver. 

Elephantiasis 

Jaundice, ob- 
structive. 

Echinococcus 
unilocularis. 

Abscess. 


Carcinoma. 

Syphilis with 
contraction. 

Ec hinococcus 
multilocularis. 

Cirrhosis. 

Adhesive pyle- 
phlebitis. 

Amyloid. 

Congestion (con- 
stant in the late 
stages). 


Echinococcus 
multilocularis. 

Acute yellow 
atrophy. 

Carcinoma. 

Syphilitic liver. 

Abscess. 


Carcinoma. 
Fatty liver. 


Echinococcus unilocularis (rarely from stasis in the 
portal system). 

Congestion. 

Syphilitic liver. 

Cirrhosis (atrophic). 

Echinococcus multilocularis. 

Hypertrophic cirrhosis. 

Amyloid. 

(Also in acute yellow atrophy and abscess due to the 
general systemic infection). 



°te. In general, the diseases are so arranged in the columns that the individual symptom of each disease increases in frequency or intensity as the column is read 

downward. 



PALPATION. 425 

and well defined. With secondary interference with 
the portal circulation, ascites occur. Jaundice occurs in 
secondary intestinal catarrh. Chronic congestion of the 
liver may also be due to malarial infection and residence 
in the tropics. 

(2) In leukaemia, Hodgkin's disease, pernicious 
anaemia and diabetes the enlargement of the liver is 
uniform, and varies with the severity of the disease. 
In leukaemia and Hodgkin's disease it is relatively less 
marked than the enlargement of the spleen and lym- 
phatic glands. The normal outline of the organ is 
retained; it is harder than normal, and the edges are 
usually sharp and well defined; the surface is smooth. 

(3) In fatty liver the organ is uniformly enlarged 
and of normal shape. The enlargement may be very 
marked, and the lower edge reach almost to the crest of 
the ilium and below the umbilicus. The feel is soft and 
elastic ; the surface is smooth, the edges round and well 
defined, and the outline can be easily made out by slight 
pressure. It is not tender to pressure, and is not 
attended with interference with portal circulation or 
enlarged spleen. 

Hypertrophic cirrhosis has many of the features of 
fatty liver. Its enlargement may be great, and it is 
harder than normal; the surface is smooth, and the 
edges sharper and well defined. With contraction of 
the connective tissue, there is diminution in size; the 
liver becomes harder, the surface and edges irregular, 
but the nodules are small, assuming gradually the 
features of cirrhosis with enlargement. The organ is 
not tender to pressure unless associated with peri- 
hepatitis. 

In amyloid liver the enlargement is marked, but the 
liver has a hard, resistant feel, and the surface is 
smooth, with sharp, well-defined edges ; sometimes, how- 
ever, they may be rounded. The edge of the liver 
cannot be moulded by firm pressure. Pain and tender- 
ness are absent. Ascites occurs in the later stages. 
(Fig. 99.) 



426 



THE ABDOMINAL ORGANS. 



In diffuse syphilitic hepatitis the liver is larger and 
firmer than normal; the surface is smooth; the edges 
are sharp and well defined, similar in many respects to 
the condition noted in amyloid liver. 

Syphilis of the liver may cause the organ to be 
nodular when gummata are formed, and when contrac- 

Fig. 99. 




Amyloid liver (due to chronic empyema), 



tion of the fibrous tissue causes depressed areas with 
intervening nodules or bosses of hypertrophied liver 
tissue. The enlargement may be marked, extending 
nearly to the umbilicus. The consistency of the nodular 
masses varies according to the amount of connective 
tissue present. Gummata, when close to the surface, are 



PALPATION. 427 

more resistant than normal liver tissue. The enlarge- 
ment of the liver is not rapid, and the nodules increase 
in size slowly. 

Cancer of the liver may cause enlargement to a vary- 
ing degree. Though it is usually massive, it may in- 
volve certain portions of the organ to a greater extent 
than others ; but the enlargements may be fairly uni- 
form. The consistency is not uniform, the cancerous 
masses being harder than other portions. The surface 
is irregular, and the irregularities may be felt as bosses 
or nodules of varying sizes. Frequently at the apex of 
a nodule a depression (umbilication) can be felt, and 
this is diagnostic of malignancy. These tumors may. 
however, be soft or semi-fluctuating. The edges are 
usually irregular, due to the projection of cancerous 
growths and to contraction of the liver substance. There 
is more or less tenderness on pressure over the promi- 
nent areas when the new growth involves the peritoneal 
coat. Ascites and jaundice occur in 50 per cent, of all 
cases. 

Abscess may develop in different portions of the liver., 
and cause irregular enlargement upward into the thorax 
or downward below the free border of the ribs and in 
the epigastric region, or outward through the thoracic 
walls. When central, it may cause a more or less uni- 
form enlargement of the organ. When it develops 
upward, the liver is displaced downward, but has the 
normal outline and characteristics. When the tumor 
develops from the lower portion of the liver, it is more 
or less globular ; its surface is smooth, and fluctuations 
may be detected when the abscess is close to the surface. 
Pain and tenderness are variable. 

Hydatid cysts of the liver may cause enlargement 
similar in many respects to that of abscess. When the 
cyst is situated on the lower border of the organ, the 
mass is globular, soft and fluctuating, and at times the 
hydatid thrill may be detected. They are painless 
unless attended with localized peritonitis. 



428 THE ABDOMINAL ORGANS. 

(4) Obstructive disease of the bile ducts, primary 
and secondary, causes hepatic enlargement. The ^ en- 
largement is usually slight, the consistency but little 
firmer than normal, the surface smooth and the edges 
well defined. Interference with portal circulation and 
enlargement of the spleen occur according to the nature 
of the cause. (See Gall Bladder.) 

Differential Diagnosis. — Differentiation by palpation 
of the uniform enlargements of the liver from each 
other and from displacements through thoracic or sub- 
diaphragmatic conditions has been described in consid- 
ering the different diseased conditions of the organs, and 
will be further discussed under percussion and ausculta- 
tion. 

The irregular enlargements may be simulated by 
other tumors occurring in organs adjacent to the liver. 
The most prominent of these are accumulations of f seces 
about the hepatic flexure of the colon (see Intestine), 
cancer of the stomach (see Stomach), right renal en- 
largement (see Kidney), puckered or indurated omen- 
tum (see Omentum), and tumors of the abdominal wall. 
Usually the differentiation is made not only by^ the 
signs obtained from palpation, but from those obtained 
by percussion and auscultation, together with the sec- 
ondary effects' of these tumors upon organs with which 
they are connected. 

The most important features of tumors of the liver 
are their mobility, their parietal situation and their 
well-defined relation to the edges of the liver, jaundice 
and ascites. Cancerous growths that involve the liver 
and neighboring organs late in the disease have no dis- 
tinctive features by which the origin of the growth can 
be determined, and the differential diagnosis is made 
from the history and the secondary effects. 

Gall Bladder. — When it is empty, the gall bladder can- 
not be felt, but when moderately distended it may be 
detected as an ill-defined mass at the edge of the right 
ninth costal cartilage, close to the outer edge of the 



PALPATION. 429 

rectus muscle, which corresponds to that point at the 
free border of the ribs where a line drawn from the 
right acromian process to the umbilicus crosses it. 

Palpable enlargements of the gall bladder are due (1) 
to distension by (a) bile, (b) mucus (hydrops), (c) 
pus (empyema) and (d) to gall stones which may be 
caused by inflammatory conditions or stenosis or ob- 
struction in the cystic or common ducts. (2) To new 
growths, malignant and benign. 

Enlargements of the gall bladder, from whatever 
cause, have certain features in common. The size varies 
greatly from a scarcely palpable tumor to one of large 
size ; usually, however, it is not larger than a good-sized 
pear. The" degree of enlargement of the same tumor 
may vary from time to time. The tumor is smooth, 
rounded and gourd-like, the large end being the most 
dependent. When the tumor becomes very large, the 
lower portion becomes more globular in relation to the 
neck, which is thin. When the distension is due to gall 
stones, the tumor may have a nodular feel. 

The tumor has a "double mobility, moving with the 
liver with respiration, and also being more or less freely 
movable in all directions about its point of attachment 
to the liver, the range of motion being one of the diag- 
nostic features of "the tumor. Generally it can be 
carried up and caused to disappear beneath the liver, 
and can also be carried to the median line; but it is 
impossible to displace it downward toward the pelvis. 

Its relations to the liver are well defined ; a sulcus can 
be usually detected between the enlarged gall bladder 
and the liver. Fluctuation cannot be detected, as the 
tumor is usually too .tense. The tenderness varies. 
When due to obstruction from gall stones, pressure over 
the tumor may cause colicky pains. 

Malignant growths of the gall bladder are usually 
hard and more or less irregular. The size in this con- 
dition is not so great as in distension by its contents. 

Enlargement "of the gall bladder may be associated 



430 TEE ABDOMINAL ORGANS. 

with enlarged liver when obstruction of the common bile 
duct occurs from any cause, and jaundice will then be a 
marked and persistent symptom. When the obstruction 
occurs in the cystic duct, jaundice, if present, is tran- 
sient, and not intense. 

Differential Diagnosis. — Tumors of the gall bladder 
may be confounded with prolongations of the lower edge 
of the liver, with hydatids of the liver, with movable 
kidneys, tumors of the intestine and tumor of the 
pylorus of the stomach. 

(1) Abnormal prolongations of the lower border of 
the liver do not have free mobility, and their outline is 
usually continuous with the smooth, convex surface of 
the liver. Their size is permanent. 

(2) Hydatid tumor attached by a pedicle may simu- 
late an elongated gall bladder. It is more distinctly 
fluctuating, and frequently hydatid thrill can be de- 
tected. It is painless, and, while it is movable, has not 
the same range of mobility as has the gall bladder, and 
it is displaced more slowly. 

(3) Movable or floating kidney has many features in 
common with enlarged gall bladder. Both tumors are 
rounded and smooth, but that of the gall bladder is 
gourd-shaped, the narrow portion projecting toward the 
fissure of the liver, the enlarged lower end lying toward 
a point just below the umbilicus. The kidney retains its 
normal shape. The feel of the two is also somewhat 
different. The gall bladder is usually firmer, and when 
filled with calculi may show an irregular outline. The 
gall bladder gives the impression of being superficial, 
and it is constantly felt when pressure is made over the 
front of the abdomen. Movable kidney, on the other 
hand, is variable in its situation, and it is not always 
detected in the same position by anterior palpation. 
The two tumors differ in range of mobility. The gall 
bladder is influenced by respiration, and the kidney, 
when situated close to organs that move synchronously 
with the diaphragm, may also have a similar motion. 



PALPATION. 431 

The gall bladder moves around a fixed point, and can be 
pushed upward to either side and backward, but not 
downward into the pelvis; and when displaced behind 
the liver towards the normal kidney-position it tends to 
return to its own normal position in front of the abdo- 
men. The kidney moves readily to different locations 
in the abdomen. It may be carried to the median line 
and beyond or downward into the pelvis, and upward 
and backward into the normal position, where it tends 
to remain until displaced by pressure over the loin or by 
posture. It slips underneath the examining fingers like 
a "greasy mass." 

When the large intestine is inflated, the gall bladder 
is pushed up and becomes more prominent. The mov- 
able kidney disappears behind the intestine, and cannot 
be felt. 

Tumors of the pyloric region of the stomach, while 
movable, do not have the same range of motion, being 
displaced farther to the loft beyond the median line, 
with a more restricted mobility to the right. Associated 
conditions are usually sufficient for diagnosis. 

Spleen. — The spleen is deeply situated underneath the 
bony thorax posteriorly, and is normally not palpable. 
except when the abdominal walls are thin and lax and 
the spleen is slightly movable, and can be pushed for- 
ward so as to be brought close to the costal maroin in the 
hypochondrium. Frequently, when the spleen is abuor- 
mally movable, turning the patient on the right side 
causes it to have an anterior position, and to be felt as 
a movable tumor. Deformitv of the thorax, esneciallv 
when involving the spine, may cause the normal spleen 
to be palpable. 

Movable or wandering spleen gives, in addition to the 
tumor that is felt at the free margin of the ribs, a 
diminished sense of resistance on palpation over the 
normal area, and a more tympanitic percussion note. 

Enlaegements of the Spleejst. — Conditions that 
increase the spleen in size cause it to develop anteriorly, 



432 THE ABDOMINAL ORGANS. 

and. to be felt under the free border of the ribs. The 
enlargements may be uniform or irregular. 

Uniform enlargement occurs (a) in infectious and 
febrile diseases. In many of these the enlargement is 
so slight as to be scarcely palpable. In typhoid fever, 
scarlet fever, small-pox, it is generally palpable, accord- 
ing to the severity of the disease. In erysipelas, sepsis 
and pyaemia, also in acute tuberculosis, the enlargement 
of the spleen may be sufficient to bring its free edge 
beyond the border of the ribs, (b) In interference with 
the portal circulation from primary disease of the liver 
(q. v.), or to cardiac or respiratory disease, (c) In 
chronic hypertrophy, due to amyloid disease, leukaemia, 
Hodgkin's disease, splenic anaemia, chronic malarial in- 
fection (ague cake), and occasionally in syphilis and 
tuberculosis. 

The irregular enlargements occur chiefly in hydatids, 

cancer and abscess. 

The characteristics of splenic tumor are: (1) They 
are superficial, and are not separated from the abdomi- 
nal walls by any of the abdominal contents. The upper 
portion disappears under the free border of the ribs, 
and cannot be defined. (2) They move with respira- 
tion, and have also a slight independent range of motion 
upward and backward on firm pressure. They have 
passive mobility toward the median line and down- 
ward when the patient is turned on the right side and 
put in the knee-chest position. (3) The tumor in uni 
form enlargements retains the normal splenic contour, 
and when it extends any distance beyond the free border 
of the ribs the notch can be easily detected. (4) The 
surface of the tumor is smooth. (5) The consistency 
varies. In acute enlargements, due to infectious and 
septic diseases, it is hard and resistant. In the irregular 
enlargements of cancer, hard, nodular bosses may be 
felt on the surface. In hydatid cyst, when the tumor 
can be readily palpated, it is tense, elastic and rounded; 
fluctuation, however, can rarely be detected, but hydatid 
thrill may be obtained. 



PALPATION. 433 

(6) The edge of the spleen is usually well defined, 
and, with the notch, is one of the diagnostic features. 

When the consistency of the spleen is soft, the edge is 
not so distinct as in some chronic enlargements, espe- 
cially malarial. 

The size of the spleen varies in different enlarge- 
ments. In the chronic enlargements of leukaemia, 
Hodffkih's disease and malaria the size is greatest The 
spleen is rarely painful, except when the peritoneal 
covering is involved, as occurs in acute inflammation, 
infarction, syphilis and abscess. Posteriorly, the 
splenic enlargement does not extend to the median line, 
so that forcible palpation below the ribs in the flank 
may enable us to distinguish the edge between the edge 
of the tumor and the erector spina? muscles. 

Differential Diagnosis. — The acute enlargements of 
the spleen cannot be differentiated by palpation. When 
dependent upon engorgement, due to obstructed portal 
circulation, the enlargement is usually associated with 
changes in the liver and heart, and there is more or less 
ascites. 

Of the chronic enlargements, amyloid enlargement is 
rarely great. It is usually associated with similar 
changes in the liver and kidney, due to prolonged sup- 
puration. In leuka?mia the splenic enlargement is 
marked, and is attended with anaemia and changes in the 
superficial glands and liver. In Hodgkin's disease the 
splenic enlargement is relatively marked, as is also the 
enlargement of the lymph glands. In ague cake the 
enlargement closely resembles in size and consistency 
that of splenic leukaemia, and the differential diagnosis 
is made on the blood examination. 

Enlargement of the spleen in anaemia (splenic 
ana?mia) occurs chiefly in children, and is not attended 
with blood changes of leukaemia or malarial infection. 

Splenic enlargement may be confounded with other 
tumors appearing in the left upper portion of the abdo- 
men, the most important of which are fecal accumula- 

28 



434 THE ABDOMINAL ORGANS. 

tions in the descending colon and sigmoid flexure. 
Faecal masses are distinguished by the absence of 
respiratory and passive motion, the rounded contour, 
absence of the notch and sharp edge, the peculiar feel, 
and the effect of treatment (purgatives). 

Cancer of the stomach, especially of the greater curva- 
ture, and the cardia may give an ill-defined tumor under 
the free border of the ribs. When the tumor becomes 
palpable in the epigastrium or below the ribs, the hard 
feel, associated with gastric symptoms, readily dis- 
tinguish it. 

The differential diagnosis between tumors of the left 
kidney and spleen will be considered below. 

Kidneys. — The normal kidney cannot be detected by 
palpation, except in children and in persons who are 
thin and have very lax abdominal walls, when the lower 
edge can be felt on bimanual palpation just underneath 
the free border of the ribs, at the end of a deep inspira- 
tion. The kidneys may be palpable when they are ab- 
normally movable or wandering, or enlarged. 

Movable kidneys are those which have a range of 
motion downward toward the pelvis, and which do not 
extend laterally into other portions of the abdomen. In 
this condition, when the patient is standing and leaning 
forward, or at the end of deep inspiration when in the 
semi-recumbent posture, the kidney may be felt to glide 
under the hand into the pelvis, so that the upper border 
can be felt. On change of position or pressure from 
below, the kidney slips back into its normal position. 
The cause of movable kidney may be enteropsis or 
emaciation in a person who has once been very stout. It 
is especially liable to occur in women who have borne 
children and with overstretched abdominal walls. An- 
terior curvature of the spine, involving the lower dorsal 
and lumbar vertebras, frequently displaces the kidney 
forward, so that it is' both seen and felt in the anterior 
portion of the abdomen. 

Wandering kidneys have a wider excursion, and may 



PALPATION. 435 

occupy any part of the abdomen, moving from place to 
place with ease, according to the posture of the patient 
and the direction of pressure. The kidney shape is 
retained, which enables one to recognize the organ; the 
borders are rounded, and the hilus is frequently palpa- 
ble. On firm pressure pain of a sickening character is 
elicited, frequently radiating down toward the bladder. 

Enlargements of the Kidney. — Enlargements of 
the kidney are due to (1) malignant disease (sarcoma 
and carcinoma), (2) cystic degeneration, (3) hydatid, 
(4) hydro- and pyo-nephrosis, and (5) perinephritic 
abscess. 

Renal tumors are extremely difficult to diagnose, and 
are frequently confounded with those of other organs. 
Their most characteristic feature is their relation to 
the surface. When they reach the anterior portion of 
the abdomen, their most prominent part is at the um- 
bilicus or just above it. They occupy the space between 
the crest of the ilium and the costal margin. Pos- 
teriorly, they fill the entire space between the lower 
border of the ribs and the pelvis, causing a smoothing 
out of the hollow of the loin, but rarely any promineuce. 
Forcible palpation in this area gives a uniform resist- 
ance, extending to the spine. The mobility of the 
tumors is but slightly influenced by respiration, 
although when they are large and in contact with the 
diaphragm, a slight respiratory mobility may be de- 
tected, but it is never as marked as in tumors of the liver 
and spleen. The statements that kidney tumor? are 
totally uninfluenced by respiration frequently lead to 
error in diagnosis. 

The size of the tumors varies sreatlv, and also that of 
the same tumor from time to time. Tumors clue to 
sarcoma, cystic degeneration and perinephritic abscess 
are stable in size, and may reach great dimensions, 
especially sarcoma in young subjects, almost filling the 
entire abdominal cavity. They rarely cause projection 
of the lower ribs or fill the pelvis. Those due to hydro- 



436 THE ABDOMINAL ORGANS. 

and pyo-nephrosis are more variable in size, according to 
the degree of distension. 

The nniform enlargements preserve to a marked, de- 
gree the kidney shape. Perinephritic abscesses, on the 
other hand, may be somewhat globular. 

The consistency of the tumor varies, being hard and 
dense in malignant disease and elastic in other forms, 
varving with the degree of tension. 

Fluctuation can rarely be detected. The relation of 
enlargement of the kidney to other structures is some- 
what characteristic. The large intestine usually over- 
lies the tumor, and can be detected by palpation and 
percussion. (Fig. 99.) The small intestine may also 
be between it and the abdominal wall. In exceptional 
cases the tumor may displace the colon downward and 
toward the median line on the right side, or carry the 
descending portion of the colon toward the median line 
so as not to be covered with it. This relation of the 
large and small intestines to the tumor overlying it dis- 
tinguishes it from splenic tumors (Fig. 98), which are 
always parietal and never have the gut between them 
and the abdominal wall, and, on the other hand, liver 
tumor, which is usually parietal, but may occasionally 
have the small intestine between the abdominal wall, 
and itself when the enlargement is irregular and is asso- 
ciated with ascites. 

Irregular Enlargements.— Irregular enlargement 
of the kidney by malignant disease or abscess may cause 
the tumor to lose its reniform shape, making it abnor- 
mally prominent in one direction ; and may also change 
the normal relation to the intestine. 

Differential Diagnosis.— -Kenal tumors are differen- 
tiated from splenic tumors by the rounded contour and 
the absence of the sharp, well-defined edge and notch ; 
also by the presence of intestine over the tumor (per- 
cussion). The renal tumors are less movable. The 
renal tumors, if they passed beneath the ribs, leave a 
palpable sulcus, due to their rounded border. Splenic 



PALPATION. 437 

tumors are in close contact with the anterior surface. 
Posteriorly, renal tumors occupy the entire space 
between the free border of ribs and crest of ilium, and 
the resistance is uniform. In splenic tumors an unoccu- 
pied area can be detected in the flank, which is also 
resonant on percussion. 

Hepatic tumors are also parietal at the costal margin, 
and the free edge of the tumor, with the sharp, well- 
defined margin, is transverse to the abdomen, following 
the normal slant of the liver. When renal tumors 
develop upward, so as to be in contact with the liver, a 
sulcus can usually be detected between the rounded edge 
of the tumor and the sharp, displaced edge of the liver. 

Ovarian tumors are parietal, and arc surrounded with 
intestines, giving resonance on percussion. They grow 
upward from the pelvis, and reach the surface just 
below the umbilicus, while renal tumors generally de- 
velop from behind forward, and first reach the abdoni 
inal wall at or a little above the umbilicus. 

The massive ovarian tumors generally become cen- 
trally situated, while renal tumors remain unilateral- 
Ovarian tumors cause displacement of the uterus up- 
ward or downward. Eenal tumors rarely involve the 

pelvis. 

Intestines. — The different portions of the intestine 
cannot be distinguished from each other by palpation. 
The small intestine normally is not palpable. It is pos- 
sible to feel certain portions of the large intestine when 
the abdominal walls are thin and relaxed. The sigmoid 
flexure of the colon can most frequently be detected, 
and. occasionally the head of the ciecum and ascending 
colon. The transverse portion cannot be made out. 
The appendix is only at times palpable, although the 
statement is frequently made that it is possible to feel 
it both by surface and bimanual palpation, one finger 
being in the rectum or vagina. Different portions of 
the intestinal canal may become palpable when dis- 
tended with gas or the walls become thickened through 



438 TEE ABDOMINAL ORGANS. 

muscular coutractiou or inflammatory products or new 
growths, or when the canal becomes filled with semi- 
fluid or solid contents. In. simple distension of the in- 
testines, with relaxation of the intestinal walls, the en- 
tire abdomen has an air-cushion feel. When the disten- 
sion is the result of chronic obstruction in any portion 
of the tract, the hypertrophied intestine may be more 
or less distinctly felt during peristalsis. 

Localized inflammatory thickening of the intestinal 
wall may occur at any point. It is rarely palpable in 
the small intestine, as it is usually associated with nar- 
rowing of the part and distension of the intestine imme- 
diately adjacent. 

Thickening of the caecum, appendix and ascending 
colon causes a tumor to be felt in the right iliac region. 
The appendix may be detected as a hard, cord-like mass, 
more or less freely movable under the finger. When 
acutely inflamed and associated with peritoneal involve* 
ment and rigidity of the muscles, the appendix cannot 
be distinguished as such, but an ill-defined tumefaction 
or a distinct tumor occupies the appendicular region, 
with a marked tenderness at a point midway between the 
anterior superior spine and the umbilicus (McBurney's 
point). 

Involvement of the caecum, with extension of inflam- 
mation to surrounding parts (typhlitis), causes a simi- 
lar tumor to be felt. Abscess formation (perityphilitic 
abscess) in this region, due to inflammation of either 
appendix or caecum, gives a less resistant tumor, with a 
sensation of deep-seated fluctuation. 

Cancer of the head of the caecum and iliocaecal valve, 
producing stenosis, causes a tumor that is hard, re- 
sistant, and, unless the neoplasm has extended to sur- 
rounding structures, nodular and movable. 

The tumor of intussusception in this region is smooth, 
uniform, and not tender on pressure. It is also asso- 
ciated with distension of the intestine, and may not be 
palpable. Tympanites is marked. 



PALPATION. 439 

Fgecal impactions, occurring in the ascending colon, 
give an oblong tnmor with a rounded contour, which 
may extend from the middle of Poupart's ligament to 
the under surface of the liver. The surface may be 
smooth, but it is usually more or less irregular or 
lumpy, and on firm pressure an indentation may be 
caused. When the pressure is removed, the walls sepa- 
rate slowly from the mass, giving a sensation of sticki- 
ness (adhesive symptom). When the frccal mass is 
hard, these symptoms may be absent, and the feel may 
closely simulate that of a cancerous tumor. 

Next to the appendicular region, the most frequent 
site of tumors is the left iliac region. The most com- 
mon tumors here are inflammatory thickening of the 
intestine secondary to diseases causing ulceration. 
Inflammatory thickening of the sigmoid flexure fre- 
quently causes it to be felt as a hard, well-defined, rope- 
like mass. Fsecal impaction and malignant disease iu 
this region have the same features as elsewhere. 

In examining the intestinal tract by palpation, in 
addition to tumors, sensitive ancl painful areas must, be 
noted. The different portions of the canal vary greatly 
in their sensitiveness to palpation. It is most sensitive 
in the region of the ca?cum, and epigastrium midway 
between the ensiform cartilage and umbilicus. The 
entire canal may become sensitive in acute intestinal 
irritation, whether inflammatory or not. Local inflam- 
mation of the intestine causes increase in sensitiveness, 
and when the peritoneum is involved there is localized 
pain, with increased rigidity of the overlying muscles. 

Differential Diagnosis. — In addition to the tumors 
already noted, the iliac regions may be invaded by 
tumors from the pelvic organs, as ovarian tumors, cysts, 
extra-uterine pregnancy, or by hernias and abscess bur- 
rowing along the psoas muscles. These are differ- 
entiated usually by vaginal examination. 

Pelvic Organs. — Tumors may arise from the uterus 
and adnexa. Tumors of the uterus may be due to 



440 THE ABDOMINAL ORGANS. 

pregnancy, nbro-myomata or fibroids. In pregnancy 
the tumor is ovoid, smooth, freely movable laterally, 
and in proportion as it extends above the pelvic brim 
the diagnostic signs of contractions and foetal movements 
are detected. Distension of the uterus from retained 
menstrual now and from growths may give the con- 
tractile symptoms of pregnancy. 

Fibroid tumors of the uterus may simulate pregnancy, 
as far as size, shape and mobility are concerned, but 
they lack the contractile sign. When they involve only 
one portion of the uterine wall they give an irregular 
tumor. 

Ovarian tumors are usually felt in the iliac regions, 
and as they increase in size assume more the medial 
position. They are usually cystic, and have a round, 
smooth, elastic feel. Fluctuation can at times be de- 
tected. Examination per vaginam shows their relation 
to the broad ligaments and uterus. They are differ- 
entiated from ascites and renal tumors by percussion. 

Parovarian cysts have many features of ovarian cysts. 
As they are usually thin-walled, fluctuation is a marked 
symptom. 

Distended bladder may give a tumor occupying the 
lower portion or the entire abdominal cavity. Its shape, 
smoothness and elasticity cause it to simulate ovarian 
tumors, ascites', pregnancy and pancreatic cysts. The 
possibility that a large abdominal tumor occupying the 
median position may be a distended bladder should 
always be borne in mind, and the viscus should be 
examined by catheter before excluding this condition. 



CHAP TEE XVII. 

PERCUSSION. 

By percussion it is possible to outline the borders of 
the solid organs of the abdomen, and by the relative 
degree of dullness or flatness to determine their relation 
to the air-containing (resonant) organs of the thoracic 
and abdominal cavities. 

When two solid organs are in contact, as the left lobe, 
of the liver and heart, it is impossible to define their 
borders by simple percussion, although at times auscul- 
tatory percussion aids in doing this by showing slight 
differences in the percussion note. The borders of the 
stomach, large and small intestine, can be determined 
only approximately, as will be explained later. 

For percussion the posture of the patient is the same 
as described under Palpation. The fingers should 
always be used both as hammer and pleximeter. The 
strength of the percussion stroke should be regulated 
according to the nature of the organ percussed, whether 
solid or "hollow, and its relation to the surface and to 
organs and tumors giving a different note. The per- 
cussion note is still further modified by the nature of 
the parietes, as the abdominal cavity is inclosed in part 
by the bony thorax and in part by the abdominal walls, 
varying in thickness and tension. As there is marked 
normal regional variation, it is necessary to be thor- 
oughly familiar with the percussion sounds present in 
the usual anatomical divisions of the abdomen. 

Left Hypochondrium. — This region includes that por- 
tion of the abdominal cavity lying beneath the ribs on 
the left side of the body. The vault of the diaphragm 
rises as high as the level of the fifth rib. The upper 



442 THE ABDOMINAL ORGANS. 

portion of this area is occupied by the thoracic viscera 
— heart and lungs, and by the abdominal organs — 
left lobe of the liver, stomach and sp]een — and the per- 
cussion sound varies accordingly. Over that portion 
where the heart and liver are parietal the note is flat. 
Just below the area of flatness, toward the edge of the 
costal arch, the thin left lobe of the liver gives a super- 
ficial dullness on light percussion, while on forcible per- 
cussion a tympanitic quality can be obtained from the 
underlying stomach. To the left of the area of cardiac 
and liver flatness the lung is parietal from the fifth to 
the lower border of the sixth rib, and the sound is that 
of pulmonary resonance, with added tympanitic quality 
from the stomach. The proportion of the two sounds 
varies with the force of the percussion and the condition 
of the stomach and lung, pulmonary resonance increas- 
ing when the lung is overdistended, as in full inspira- 
tion or emphysematous dilatation ; diminishing with re- 
traction of the lung from any cause, and becoming flat 
when the complemental space of the pleura is filled by 
effusion. Distension of the stomach or displacement 
upward of this organ by increased abdominal pressure 
causes a relatively higher position of the diaphragm and 
corresponding increase in stomach resonance. 

Half-Moon Space (Traube). — This embraces all 
that portion of the lower thorax below a concentric line 
starting from the cardio-hepatic flatness in the sixth 
interspace, and extending downward to the anterior 
axillary line or mid-axillary line, which corresponds 
approximately to the lower border of the lung. In this 
space the stomach is parietal, and the note is high 
pitched and tympanitic, with a peculiar metallic, echo- 
like quality (stomach tympany). 

The percussion note over this space may be altered by 
a number of conditions. (1) The upper boundary may 
be invaded by pulmonary resonance, due to increase in 
size of the lung, with depression of the diaphragm. 
(2) It may be flat from depression of the diaphragm by 



PERCUSSION. 443 

pleurisy with effusion. (3) The normal stomach 
tympany may be replaced by flatness, due to the filling 
of the organ with food or liquid. (4) Enlargement 
anteriorly of the left lobe of the liver from any cause 
may give an area of flatness or dullness. (5) Toward 
the axillary line in the region of the ninth to the elev- 
enth rib enlargement of the spleen may give dullness or 
flatness. (6) Distension of the colon may give change 
in the tympanitic sound. 

The Splenic Area. — This area is to the left of the 
half-moon space, and limits it in that direction. 
Although the spleen is contained in the abdominal 
cavity, with its long axis parallel to the tenth rib, and 
occupying the space between the ninth and the tenth ribs 
from the mid-axillary line in front to within 1% to 2 
inches of the vertebral column behind, under normal 
conditions but a small portion of its anterior border ap- 
proaches the surface. On account of its respiratory and 
passive mobility, its position and corresponding effect 
on the percussion note will vary according to the posture 
of the patient. When lying on the back, it is displaced 
posteriorly; when lying on the right side, it is more 
anterior, out further removed from the surface. In the 
erect posture its position is more nearly horizontal, and 
slightly lower. It is impossible to accurately outline 
the normal spleen by percussion, surrounded and in part 
overlapped as it is by air-containing structures. The 
dullness obtained is only relative to the pulmonary 
resonance above and stomach tympany anteriorly, intes- 
tinal tympany below and flatness of lumbar muscles and 
kidney posteriorly. 

To determine the splenic area dullness, the percussion 
blow must vary according to the nature and condition of 
the overlying structures. Over the portion covered by 
the lung, beginning beyond the normal area, the per- 
cussion is first made toward the spleen with fairly strong 
blows until slight deep-seated relative dullness is de- 
tected. From this point the percussion proceeds with 



444 THE ABDOMINAL ORGANS. 

gradually diminishing force. From the gastric and in- 
testinal borders only light percussion is used. In the 
normal condition of the lung, with stomach and intes- 
tine empty and not distended with gas, a small area of 
splenic dullness may be detected in the mid-axillary line 
or between it and the post-axillary line and between the 
lower edge of the ninth and upper edge of the eleventh 
ribs. Beyond this area the splenic dullness becomes 
progressively masked by increased pulmonary resonance 
as percussion proceeds toward the posterior border. 

The size and position of the area of splenic dullness 
varies with the respiratory movements, being larger at 
the end of expiration and smaller or disappearing dur- 
ing inspiration. On account of the relation of the 
spleen to surrounding organs, the normal area of splenio 
dullness may be replaced (a) by increased resonance ; 
(b) increased dullness or flatness. Increased resonance 
over the splenic area may be due to depression of the 
lower border of the left lung, dependent upon emphy- 
sema or to distension of the stomach and intestines, large 
and small, with gas (tympanites). Diffused dullness in 
the splenic area may be caused by consolidation of the 
lung overlapping the spleen, left pleural effusion or 
pleural thickening ; fluid distending the stomach, or fill- 
ing of the transverse portion or splenic flexure of the 
colon with f seces ; also by general ascites. Absolute in- 
crease in splenic dullness occurs in all enlargements of 
the spleen, and when that organ becomes more parietal. 
On account of the effect of surrounding organs upon 
splenic dullness, the diagnosis of enlargement of the 
spleen should not be made by percussion alone, but the 
results should be corroborated by palpation. 

Right Hypochondrium. — In the right hypochondrium 
all of that portion of the abdominal cavity that is 
covered anteriorly by the thorax is occupied by the liver, 
the upper border of which rises as high in the mammary 
line as the fifth rib, corresponding to the dome of the 
diaphragm. 



PERCUSSION. 



445 



Percussion over the liver gives two areas. The first 
corresponds with that portion which is separated from 
the thoracic wall by the lung — the area of relative dull- 
ness; and the second, that portion where the liver is 
parietal — the area of liver flatness. 

The pneumo-hepatic border of the liver corresponds 
to a line that separates the relative hepatic dullness from 

Fig. 100. 




Absolute and relative heart and liver dullness, also regional variation 

in thorax. 

hepatic flatness. The position of this border and the 
area of hepatic flatness will vary according to the con- 
dition of the right lung, the border being lower and the 
area of hepatic flatness smaller with full inspiration anc^ 
in emphysema, and the border being elevated with in- 
crease in the area of flatness in expiration and diminu- 
tion of the size of the lung. The relative liver dullness 



446 THE ABDOMINAL ORGANS. 

cannot be detected over the entire upper portion of the 
liver, as the pulmonary tissue is too thick for the liver 
to be reached by the percussion vibration. (Fig. 100.) 

The point at which the influence of the underlying 
liver upon pulmonary percussion will be detected will 
depend markedly upon the force of the percussion blow, 
which will also influence the determination of the 
pneumo-hepatic border. Proceeding from above down- 
ward, the percussion blows should be progressively 
lighter as the lower border of the lung is approached, 
where only the lightest stroke should be employed. 

The pneumo-hepatic border should be determined by 
percussion from the area of relative dullness to absolute 
flatness, and also beginning over the flat area by per- 
cussing toward the area of relative dullness until faint 
resonance is detected. Normally the pneumo-hepatic 
border extends from the base of the ensiform cartilage 
in the median line to the upper border of the sixth rib 
in the mammary line, and to the eighth rib of the mid- 
axillary line. Well-marked liver dullness extends one 
or more interspaces higher, gradually shading off into 
pure pulmonary resonance. 

The area of absolute flatness on the anterior portion 
of the chest extends from the pneumo-hepatic border to 
the free border of the ribs. Over the lower portion the 
thinness of the liver permits percussion vibration to 
reach the underlying air-containing organs, and gives a 
slight tympanitic quality to the note. 

Conditions Modifying the Area of Flatness 
Over the Liver. — The area of liver flatness may be 
enlarged upward by: 1. Changes in the thoracic organs 
due to (a) consolidation of that portion of the lung over- 
lying the liver, (b) Eetraction of the lung, causing 
greater portion of the liver to become parietal, (c) 
Effusion into the right pleural cavity or thickening of 
the pleura. 2. Displacement of the liver upward from 
any cause. In this condition the lower part of the liver 
is also raised above the normal limit. 3. Absolute en- 



PERCUSSIOX. 447 

largement of the liver, which may be uniform or irreg- 
ular, corresponding to the conditions noted under Pal- 
pation. In these conditions the enlargement of the liver 
upward is not so great as downward, except when 
secondary changes produce increase in the intra-abdomi- 
nal pressure and displacement upward of the liver and 
diaphragm. 

In irregular enlargements or tumors, the outline 
corresponds to the location of the tumors. 

Extension of the area of flatness downward may be 
due to displacement from thoracic disease, causing 
descent of the diaphragm and liver. In this condition 
the liver may be forced down below the free edge of the 
ribs, and the area of absolute dullness is only relatively 
increased, the pneumo-hepatic border being also de- 
pressed. Absolute enlargement of the liver, uniform 
or irregular, causes the area of flatness to extend accord- 
ing to the change occurring in the liver. 

Solid tumors or fluid extending to the liver cause the 
flatness to extend beyond the normal liver area. 

Decrease in the area of hepatic flatness may be 
apparent or absolute. It is seemingly diminished 
whenever the area of normal flatness is encroached upon 
by distension of the lung above or by the stomach or 
intestine below. The greatest diminution in the size of 
the liver occurs in cirrhosis and in acute yellow atrophy. 

The True Abdomen.— Percussion of all the anterior 
portion of the abdomen not inclosed by the thorax gives 
a tympanitic note, due to the underlying air-containing 
organs. In the epigastrium the stomach is overlapped 
by the left lobe of the liver, which is too thin to prevent 
the percussion vibration reaching the stomach. On 
light percussion, slight dullness due to the liver may be 
detected. 

The percussion note obtained over the stomach, large 
and small intestines, is tympanitic in quality, and varies 
slightly in pitch over the different segments, according 
to the amount of air contained and the tension of the 



448 THE ABDOMINAL ORGANS. 

walls ; but it is difficult to determine accurately the out- 
line of the stomach and large and small intestines, on 
account of their varying size and degree of distension. 

To determine the lower border of the stomach, it is 
examined when filled with fluid or artificially distended 
with air. When the patient is in the recumbent posture, 
the fluid gravitates to the most dependent portion; the 
note obtained over the viscus on percussion is tympanitic, 
and its lower limit is separated from the adjacent large 
intestine by a difference in pitch. The patient then 
assuming the upright position, the fluid — the amount, of 
which may be increased by drinking water — causes the 
lower segment, which was previously tympanitic, to be- 
come flat on percussion. 

Distension of the stomach by forcing air through a 
stomach tube, or by the production of carbon dioxide by 
having the patient drink separately a solution of tartaric 
acid (5ss) and one of bicarbonate of soda (3ss), causes 
the note to become markedly tympanitic and ringing. 
When it is not safe to cause forcible distension of the 
stomach, the large intesiine may be distended by forcing 
gas from a Davidson syringe into the rectum, and so 
causing a difference in the pitch of the distended colon 
from that of the more relaxed stomach. 

Conditions Modifying Abdominal Resonance. 
Thickened Abdominal Wades. — Increased thickness 
of the abdominal walls, especially when due to fat. and 
also accumulations of fat in the omentum (omental 
lipoma), cause a slight diminution of resonance over the 
entire abdomen, which, however, is not sufficient to 
obliterate the tympanitic resonance of the stomach and 
intestines, but which masks the normal outline of th^ 
solid organs and renders the detection of tumors diffi- 
cult, especially when they are small and not entirely 

parietal. 

Fluid in the Abdominal Cavity, Ascites. — A 
small amount of fluid does not modify the percussion 
note over the abdomen, as the fluid gravitates to the mosi 



PERCUSSION. -±49 

dependent portion, according to the posture. When 
sufficient in amount to rise above the symphysis in the 
erect position and above the heavy muscles of the flank 
in the recumbent posture, it gives a flat note where it is 
parietal, and, as the intestines are floated on the surface 
of the liquid, a tympanitic note is found above its level, 
which is alwavs horizontal. 

As the fluid moves freely in the abdominal cavity, the 
line of flatness and the area of tympany change with 
alteration of posture. As the fluid gives a flat note, like 
that of solid organs, it is always necessary to change the 
position of the patient in determining whether or not 
the extension of dullness bevond the normal limits is due 

» 

to effusion into the abdominal cavity or to absolute in- 
crease in size of the solid organs. 

AVhen the abdominal cavity is extensively distended 
with fluid, or when the fluid is encapsulated, free move- 
ment may not occur. Although usually the intestines 
float above the fluid, adhesions or short mesentery may 
bind them down so as to prevent this. 

The relation of the area of tympanitic resonance to 
that of flatness is important in differential diagnosis of 
flatness due to ascites from abdominal tumors. In 
ascites, with the patient in the recumbent posture, the 
area of tympanitic resonance occupies the center of the 
abdomen around the umbilicus, changing position with 
that of the patient, and always resuming the uppermost 
position ; while in solid tumors which are parietal the 
dullness occupies the most prominent portion of the 
abdomen, and is surrounded by tympanitic resonance, 
which does not change with altered posture. ( 

Abdomixal Tumoes. — Abdominal tumors cause 
diminution in resonance according as they are perietal. 

Tumors of the stomach and intestine are rarely large 
enough to give well-marked flatness, although when asso- 
ciated with thickened peritoneum there may b? a slight 
diminution of resonance. 

Faecal accumulations in the large intestine mav be 

29 



450 



TEE ABDOMINAL ORGANS. 



detected by percussion, as they are usually parietal. 
They may easily be detected when they occupy the 
caecum, the ascending colon or the sigmoid flexure. 



Fig. 101. 



Fig. 102. 




Flatness 



Resonance 
of colon 




Flatness 



Tumor of spleen. 

X Resonance between posterior margin 

and lumbar muscles. 



Tumor of left kidney. 



When situated in the hepatic or splenic flexures, they 
increase the areas of dullness of liver or spleen. 

Enlargements of the liver and spleen, when they 



PERCUSSION. 451 

extend beyond the ribs into the abdominal cavity, give 
well-marked areas of flatness, sharply denned by the 
surrounding intestines. The enlarged organs are 
parietal, but it is only in exceptional conditions that a 
portion of the intestine intervenes between it and the 
abdominal wall. Tumors springing from the under 
surface of the liver, as hydatids, or irregular enlarge- 
ments, as cancer, may have intestine in front. 

Posteriorly the liver dullness does not extend to the 
spine, but well-marked splenic dullness may extend to 
the spine in the upper portion, while lower down there 
is an area of resonance between the tumor anteriorly 
and the edge of the lumbar muscles posteriorly. (Fig. 
101.) 

Tumors of the kidney are not parietal throughout, 
and the area of flatness is usually divided by the colon 
in front of it. Posteriorly the flatness extends to the 
spine throughout. (Pig. 102.) 

In tumors' of the pelvic organs the dullness extends 
upward from the pubic arch, and is surrounded by 
intestinal resonance in the flank and above. Dullness 
over the tumors may be diminished by distension of the 
intestine with gas (meteor ism) or by air in the peri- 
toneal cavity (perforative peritonitis). 

When dullness in the flank is present, not extending 
also to the central zone of the abdomen, with resonance 
between the dullness and the central portion of the 
abdomen and the pelvic brim, the tumor is not of pelvic 
origin, but is from the deeper tissues (pancreas, retro- 
peritoneal glands, etc.). 



CHAPTEK XVIII. 

AUSCULTATION. 

Auscultation of the abdominal organs gives very 
little aid in differential diagnosis, and is limited to (a) 
splashing sounds made in hollow organs containing both 
air and fluid ; (b) gurgling, churning or cooing sounds, 
due to passage of fluid through the intestinal canal; 
(c) friction sounds, produced by the roughened peri- 
toneum over solid or hollow organs which move with 
respiration ; (d) vascular or haemic sounds. 

(a) Splashing sounds (succussion) may be heard over 
the stomach and large intestines when they are agitated 
with short, sharp blows with the tips of the fingers. 

In the stomach this occurs when the viscus contains 
both air and fluid and is to a certain degree relaxed. It 
was formerly considered diagnostic of gastroectasis, but 
can occur without any pathological condition of the 
stomach being present. Its chief value as a sign of en- 
larged stomach is in finding it persistently below the 
normal limit of the stomach. 

Over the caecum, on account of the liquid character of 
its contents, succussion sounds may also be produced. 
When found beyond the head of the caecum, especially in 
the transverse portion of the colon, it indicates an abnor- 
mally liquid state of the faecal mass in these locations. 
In the small intestine succussion cannot be induced. 

(b) Gurgling or churning sounds are heard over the 
stomach and intestines, due to the passage of liquids 
from the narrowed portions into the wider areas beyond. 
Over the cardia, normally, a hissing murmur is heard 
soon after swallowing liquids. In obstruction at the 
cardia from any cause, the normal deglutition sound 



AUSCULTATION. 453 

may be replaced by a gurgling or rushing sound occur- 
ring at a relatively later period, and due to the forcing 
of the contents of the oesophagus through the ob- 
struction. 

Over the small and large intestines, normally, cooing, 
gurgling sounds are heard. When the intestines are 
distended with gas and the peristaltic activity is in- 
creased, this may become loud enough to be heard at 
some distance from the patient. 

In tympanites with lessened peristalsis, as occurs in 
paralysis of the intestines, and in peritonitis, absence of 
this normal sound in proportion to the distension is of 
diagnostic importance. 

Over the ileo-ca?cal valve, gurgling can frequently be 
heard on firm pressure. This has been frequently cited 
as one of the symptoms of typhoid fever, but it is not 
pathognomonic of this disease, as it occurs whenever the 
contents of the small intestine are more liquid than 
normal and when there is slight distension of the ileum 
with gas. 

(c) Friction sounds are heard whenever the peri- 
toneal coats are covered with inflammatory exudate and 
there is free movement between the surfaces. This is 
most marked in perihepatitis and perisplenitis, provided 
the normal respiratory mobility of the liver and spleen is 
not interfered with. It is rarely heard over hollow 
organs, although in acute localized inflammation of the 
stomach it may be present. The quality of the sound 
will vary according to the character of the exudation. 
In fibrinous exudation it occurs as fine, crackling rales. 
When adhesions are present, creaking, crumpling fric- 
tion sounds may be heard. 

(d) Vascular or fcsemic murmurs may be heard over 
different portions of the abdomen. Solid tumors and 
growths pressing on the aorta or large blood-vessels may 
cause sufficient narrowing to induce a murmur, which 
is conveyed by the tumor to the surface, and is heard as 
a bruit, synchronous with the first sound of the heart. 



454 THE ABDOMINAL ORGANS. 

or it may be a little delayed. Aneurismal dilatation of 
the aorta or abdominal vessels may cause a similar mur- 
mur to be heard. They are differentiated from pressure 
murmurs by the presence of expansile pulsations. 

Over the liver a systolic murmur may be heard, due 
to the conveyance of tricuspid regurgitant murmur. 

In tumors of the uterus, arterial sounds may be 
present. In pregnancy, in addition to the uterine 
souffle, there is heard the foetal heart beat. Hsemic 
sounds, simulating the uterine souffle, may also be heard 
in extra-uterine pregnancy and in vascular tumors of 
the uterus, but the foetal heart sound is not heard. 



PART V. 
EXAMINATION WITH X-RAY. 



For, making X-ray examination of the body, it is 
necessary to have apparatus of great power, and also 
means for adjusting the quality of the ray emitted by 
the tube, which may be accomplished either by inserting 
a series of spark caps in the circuit connecting the tube 
or by adjusting the vacuum of the tube. There are on 
the market a number of tubes provided with vacuum 
regulating devices, all of which depend for their action 
upon the liberation of a little gas from some salt which 
is contained in a small chamber connected with the tube. 

The exciting apparatus may be either a static ma- 
chine, an ordinary induction coil, or a coil of high fre- 
quency type. If an induction coil is used, it should be 
capable of delivering heavy sparks, 10 or 15 inches long, 
and should be provided with means for giving very 
rapid interruptions of the primary circuit. The turbine 
mercury interrupters and the liquid or electrolytic 
interruptions are available for this purpose. The 
induction coil has the advantage that it occupies a 
comparatively small space, and its action is not affected 
by the weather. If the static machine is used, it should 
be of a rather large size, having, for example, 10 to 16 
revolving plates of about 30 inches diameter. The static 
machine gives a very steady excitation of the Crookes 
tube, and is therefore very satisfactory for fluoroscopic 
examinations. It is, however, more or less susceptible 
to changes in weather conditions. 

On account of the constant movements of respiration, 



456 EXAMINATION WITH X-RAY. 

the fluoroscope examination of the thoracic viscera is 
perhaps more satisfactory than the radiograph. Mnch 
valuable information may be obtained by observing the 
movements of the parts, as, for example, the excursions 
of the diaphragm, the pulsations of the heart or of 
aneurism, the change of level of fluid in the pleural 
cavity, due to change of position of the subject, etc. 
The facility with which these examinations can be made 
and the accuracy of their findings will vary with dif- 
ferent subjects. Obviously, a small, thin subject will 
give a more satisfactory fluoroscopic picture than a 
large, muscular one. At first it may seem that by in- 
creasing the intensity and penetrating power of the rays 
we could examine a large subject as well as a small one, 
but this is not the case. It is easy enough to produce X- 
rays of sufficient intensity to penetrate any human body, 
but in order to make a satisfactory fluoroscopic examina- 
tion or radiograph it is necessary that these rays be in- 
tercepted to varying extents by the different structures 
under examination, so that they will cast shadows of 
discriminable density. A thick layer of muscular or 
adipose tissue, although it may transmit the ray, to a 
certain extent confuses the shadow of substances of less 
capacity which lie beneath it; hence it is impossible to 
differentiate the tissues under examination by increas- 
ing the power of the X-rays. 

Fluoroscopic examinations should be made in a dark- 
ened room. It will be found that it takes the average 
eye from ^ve to fifteen minutes to adjust itself so as to 
use the fluoroscope to the best advantage. All clothing 
should be removed from the patient, and the examina- 
tions can be conveniently made with the patient in a sit- 
ting position, with the arms resting over the head, so as 
to draw the scapulae away from the median line. It is 
well to have two fluoroscopes — a large one, which will 
show the entire region, and a smaller one, with which 
small parts may be examined and the light from a large 
area excluded. Sometimes it will be convenient to ex- 



EXAMINATION WITH X-RAY. 457 

amine the patient in a recumbent position. In this case 
it is well to place the subject on a stretcher, placing the 
tube underneath and the fluoroscope above. The canvas 
of the stretcher offers very little obstruction to the X- 
ray. A protective screen of thin aluminum is some- 
times interposed between the X-ray tube and the sub- 
ject under examination, to prevent any burning by the 
rays. This screen offers very little obstruction to the 
X-ray, and therefore interferes very little with the 
examination. 

For the reasons pointed out above, the radiograph of 
the thorax will usually not be so satisfactory as the 
fluoroscopic examination, though it may be valuable as a 
permanent record. The apparatus required for making 
the radiographs will be practically the same as those 
described for fluoroscopic examinations, with the addi- 
tion of necessary plates, etc. 

Observations by means of the X-ray of the thorax and 
abdomen presents many points of interest to the 
clinician. A thorough knowledge of the normal appear- 
ance of the different parts of the bodv under the X-rav 

it/ t/ 

is absolutely necessary for the proper use of the fluoro- 
scope, and for correct interpretation of the skiagraphs 
as a means of diagnosis, otherwise false interpretation 
will be made. The use of the X-ray in medicine 
should be accompanied by the use of other methods of 
diagnosis, and should never be relied upon alone. 

Tor the beginner, the subject to be examined should 
be carefully selected. A young person, preferably an 
adult male about twenty years old, and not too fleshy, is 
the best. It should be constantly borne in mind that 
each subject will present a picture that has certain 
individual peculiarities., according to the thickness of 
the soft parts, the bony structures and antero-posterior 
diameter of the chest. The fluoroscope has many advan- 
tages over the skiagraph for a beginner, as the outlines 
are more distinct, and it is possible, by varying the 
intensity of the light, to obtain a better view of the 



458 EXAMINATION WITH X-RAY. 

thoracic and abdominal organs and to determine their 
outlines. 

The Normal Picture. — As in other methods of diagno- 
sis, the examination should be systematically conducted. 
At first a general inspection of the thorax from above 
downward is made. The picture upon the screen shows 
in the median line corresponding to the sternum, spinal 
column and mediastinal spaces, a dark shadow at the 
level of the third rib, which widens out into a more or 
less spherical figure, corresponding to the ventricles, and 
resting in the dome of the diaphragm, which appears as 
a dark line. On either side of this central shadow ap- 
pears a light field, corresponding to the pulmonary tis- 
sue, which should present a thin, foggy, uniform shadow, 
varying during the phases of the respiratory act, being 
lighter on full inspiration and darker at the end of 
expiration, according to the rarefaction of the lung. 
Traversing the light area of pulmonary tissue, the ribs 
are noted, their prominence varying with the intensity 
of the light used. Beyond the thorax, the body structures 
and soft parts are readily distinguishable. (Plates VII 
and VIII.) 

In addition to the outline of the organs above men- 
tioned, the extent of their motion should also be noted. 
Ventricular contraction is well defined, also slight pul- 
sation of the aorta can be seen. The line of the dia- 
phragm varies with the respiratory act, descending with 
inspiration, when the complemental spaces of the pleura 
become distinguishable as a transparent area. The 
movements of the diaphragm should be uniform, both 
sides acting simultaneously and to the same extent. 
With the descent of the diaphragm and rarefaction of 
the lung, the cardiac position changes and the outline 
becomes more distinct. 

The Effect of Changes in the Lung on the Fluoroscopic 
Picture. — These may cause the shadows to be more 
intense and darker when the density of the lung is 
changed by increase in the normal structure or by fill- 



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Radiograph of Diffuse Tuber culosis of the Left Lung. 
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EXAMINATION WITH X-RAY. 459 

iiig of the alveolar spaces ; or the opposite when rarefac- 
tion of the lung occurs from increased size of the 
alveolar spaces, or when there is destruction of tissue 
with cavity formation. They may also cause change in 
the movements of the diaphragm and in the position of 
the heart and mediastinal structures. 

Conditions Causing Dakk Abeas. — Tuberculosis. 
It should be borne in mind that the right apex is not so 
markedly transparent as the left. This corresponds to 
the normal variation noted under palpation, percussion 
and auscultation. The amount of darkening will corre- 
spond to the degree of change. (Plates IX and X.) 

^ As in other methods of examination, the fluoroscopic 
picture of the two sides is comparative, and should 
always be judged on this basis. When the tubercular 
area is central and surrounded by emphysematous lung, 
the shadow of the affected portion is more pronounced. 
In the incipient cases a slight denseness in the shadow 
will be observed in one apex when carefully considered 
in comparison with clearness of the normal shadow, and 
with the apex on the other side. As the pathological 
process extends until consolidation or cavity results^ the 
shadow will progressively become deeper and larger 
until the change on the two sides is very marked. The 
fibroid changes are evident by the absence of the normal 
foggy shadow and by a more dense shadow over the areas 
involved. (Plate XL) This condition is often notice- 
noticeable in the lower portion of the chest, secondary to 
the diaphragmatic involvement. Retraction and thick- 
ening of the pleura give a darker shadow, and marked 
loss of motion over the affected area. (Plate XII.) 

Pneumonic consolidation. In lobular pneumonia 
the dark areas correspond to the site of the lesion, and 
have the same general appearance as those of tubercular 
infiltration. Croupous pneumonia 2;ives a well-defined 
shadow, corresponding to the degree of consolidation 
and the division of the lobes. Radioscopy aids greatly 
in differentiating pneumonia from primary or compli- 



460 EXAMINATION WITH X-RAY. 

eating effusion, showing the relation of the lung to the 
diaphragm. In pneumonia, on full inspiration, the 
descent of the diaphragm shows a light line between the 
lung and the moving shadow of the diaphragm. When 
effusion occurs, primary or secondary, this line is not 
seen. Pleural effusions cause a uniform dark shadow. 
The character of the fluid does not influence this shadow. 
In addition to the shadow caused by the fluid, it is 
possible to determine the line that the fluid assumes in 
the chest and the amount of displacement of the thoracic 

viscera. 

Calcareous deposits in the lung or fibroid thickening 
also cause slight shadows. The bronchi may give an 
ill-defined shadow on either side of the median dark 
space, and must always be considered. Enlargements 
of the glands cause shadows to appear. 

Conditions Causing Lighter Shadows. — The lung 
transmits light more readily in emphysema, and 
there is less change of shadoAV during respiration. The 
movements of the diaphragm are not as great ; the heart 
appears unusually clear, arid also assumes the typical 
position. In pneumo- and hydro-pneumothorax the 
shadow is less marked over that portion of the pleura 
which contain air (Plate XIII), while when fluid is pres- 
ent a dark shadow is seen below its level. The upper 
level assumes a horizontal line, in contradistinction to 
the curved line seen in simple effusion. In hydro- 
pneumothorax the splashing of the fluid is plainly seen 
on shaking the patient, and also the change of level on 
his changing position. The pulmonary shadow is pres- 
ent above the level of the fluid, and is slightly deeper in 
density, owing to the compression. In pneumothorax 
the lack of motion of the diaphragm during inspiration 
is the most striking feature. The displacement of the 
heart and the relatively denser shadow of the opposite 
lung are diagnostic. Cavity formation also gives a well- 
marked light area. When the walls of the cavity con- 
tain calcareous deposit, or the cavity is surrounded by 
consolidated lung, a shadow may replace the light area. 



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EXAMINATION WITH X-RAY. 461 

Examination of the Circulatory System. — For satisfac- 
tory examination of the borders of the heart, the lung 
and pleura must be clear. Normally a dark shadow is 
caused by the ventricles, while the right auricle causes 
a faint shadow to be seen just to the right, and on the 
left a fainter shadow is caused bv the left auricle. The 
rarefaction of the lung causes these shadows produced 
by the auricles to become clearer, so that they are more 
pronounced at the end of full inspiration than in expira- 
tion, and also in emphysematous dilatation than in nor- 
mal lung. Dilatation of the cavities or distension by 
blood causes a correspondingly darker shadow. As has 
been mentioned, the intensity of the shadows will vary 
according to- the amount of light used. The pulsations 
of the heart and aorta may be seen, especially during 
inspiration. 

The exact cardiac outline can be mapped out on the 
chest by means of an indelible pencil; the lower end 
encircled in the metal cylinder. After carefully outlin- 
ing the heart and locating the apex, the tracing can be 
made direct from the chest wall. The tracing should 

O 

include the nipple and one or two bony parts of the 
chest. This chart can be filed and retained as a perma- 
nent record. 

Cardiac Diseases. — The fluoroscope, in selected cardiac 
cases, will materially assist in determining the cardiac 
area, shape and relation to the surrounding viscera. In 
the following diseases important points will be enumer- 
ated in detail: 

Pericarditis with Effusion. — The fluid in peri- 
carditis changes the shape of the cardiac shadow, giving 
the broad base below; the pulsating apex is less 
visible. A point of great value in this condition can be 
noted on deep inspiration; as the diaphragm descends 
the pericardium can be seen to pull away from the 
cardiac mass, and is distinguished bv the slight change 
in density between the pericardial fluid and the cardiac 
wall. 



462 EXAMINATION WITH X-RAY. 

Adhesive Pericarditis. — The displacements due to 
retraction are visible, and also those which occnr when 
the pericardinm is displaced by fibroid changes in the 
lung. 

Hypertrophy and Dilatation. — Changes in size 
and in the shape of the cardiac shadow can be, by means 
of the scheme outlined above, readily observed and re- 
corded accurately for future observation. (Plate XI V.) 

Mitrae Stenosis. — The change in the shape of the 
heart in this condition is very noticeable. The axis of 
the shadow is changed; the apex is carried upward and 
to the left, and the long diameter is almost parallel with 
the diaphragm. 

Aneurism. — The localization of aneurism at the 
base of the heart, or involving the arch of the aorta, is 
probably one of the most important results of fluoro- 
scopic work. The bulging of the vascular wall can bo 
noted accurately, and its relation to the base of the heart 
or great vessels plainlv demonstrated. (Plates XV and 

XVI.) 

The Radiogragh in Cardiac Diseases. — The radiograph 
in cardiac diseases has been of much less assistance than 
the fluoroscope, yet, where available, it places in our 
hands an absolute picture of the conditions under con- 
sideration. In many subjects a radiograph can be 
obtained which will determine the outline and position 
of the heart, location and size of the aneurisms of dif- 
ferent portions of the aorta. 



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Radiograph of Aneurism of Ascending Portion of Thoracic Aorta. 



INDEX. 



Abdomen, anatomy of, 37 
auscultation of, 452 
decrease in size of, 411 
enlargement of, 408 
causes of, 408 

local, 409 
epigastric region, 409 
hypogastric region, 410 
lateral region, upper lef 1,4 10 
right, 411 
lower left, 411 
right, 411 
umbilical region, 409 
examination of parieties, 406 
movements of, 406 
respiratory, 406 
visceral, 407 
percussion of, 441 
regional anatomy of, 37 
regions of, 37 
true percussion of, 446 
tumors of, percussion over, 
450 
Abdominal aorta, anatomy of, 42 
organs, 405 

regions, table of contents of, 38 
walls, palpation of, 413 
tension of, 413 
tumors of. 413 
Abscess of liver, 427 

of spleen, 433 
Actinomycosis. 218 

condition of lung in, 218 
physical signs of, 218 
stages of, 218 
Adherent pericardium, 379 
cardiac sounds in, 388 
differential diagnosis of, 389 



Adherent pericardium, friction 
sounds in. 389 
retraction of chest wall in, 
381 
Adventitious sounds, 123 
iEgophony, 148 

in pericarditis with effusion, 
388 
Alar chest. 48 
Amphoric breathing, 123 

resonance. 148 
Anaemia, arterial pulsations in, 
246 
pernicious, liver in, 425 
venous pulsation in. 247 
Anaemic murmurs, 298 

in pulmonic area. 365 
Anatomy, topographical and 

relational, 17 
Aneurism of aorta. 393 

apex beat in. 395, 397. 398 
bruit in. 399 

bulging of chest wall in. 394 
cardiac sounds in, 399 
diastolic murmur in. 399 
differential diagnosis of. 401 
differentiated from aortic 
stenosis, 350 
from asthma, 202 
Drummond's sign in, 400 
dysphagia in, 397 
fluoroscopic examination of, 

462 
forms of, 393 
palpation, 256 
physical signs of, 394 
pressure signs in, 394 
pulsating tumor in, 395 
pulse in, 397 
Sanson's sign in, 400 



464 



INDEX. 



Aneurism of aorta, superficial 
veins in, 395 
thrill in, 396 
tracheal tugging in, 397 
traction of pupil in, 395 
of thoracic aorta, 245 
Aneurismal murmurs differen- 
tiated from pulmonary ob- 
struction, 366 
Aorta, abdominal, anatomy of, 42 

anatomy of, 35 
aneurism of, 393 

apex beat in, 395, 397, 398 

bruit in, 399 

bulging of chest Avail in, 

394 
cardiac sounds in, 399 
diastolic murmur in, 399 
differential diagnosis of, 401 
differentiated from asthma, 

202 
Drummond's sign in, 400 
dysphagia in, 397 
physical signs of, 394 
pressure signs in, 394 
pulse in, 397 
Sanson's sign in, 400 
superficial veins in, 395 
thrill in, 396 
tracheal tugging in, 397 
traction of pupil in, 395 
percussion of. 284 
relations of, 35 
thoracic, aneurism of, 245 
Aortic diastolic murmurs, 310 
regurgitation, arterial pulsa- 
tions in, 245 
capillary pulse in, 246 
causes of, 351 
differentiated from mitral 

stenosis, 343 
effects of, 352 
location of apex beat in, 

354 
murmurs in, 357 
physical signs of, 354 
pulsation of blood-vessels 

in, 354 
pulse in, 355 

water hammer, 356 
sound, accentuation of, 294 
stenosis, 343 



Aortic stenosis, area of cardiac 
flatness in, 347 

causes of, 344 

diagnosis of pathological 
condition in, 348 

differential diagnosis of, 350 

differentiated from tricus- 
pid regurgitation, 373 

effects of, 344 

location of apex beat in, 
345 

murmur of, 347 

physical signs of, 345 

pulse in, 346 

thrill in, 346 
systolic murmurs, 309 

differentiated from pul- 
monary obstruction, 366 

Apex beat, cause of, 238 

conditions modifying char- 
acter of, 240 
extent of, 240 
location of, 240 
influence of abdominal 
changes on, 245 
bony thorax -on, 240 
in children, 240 
in old age, 240 
changes in heart on, 243 
in lung on, 242 
in mediastinum on, 245 
in pericardium on, 243 
of soft parts on, 240 
of diseases of pleura on, 
241* 
location of, 238 

in aneurism of aorta, 

395, 397, 398 
in aortic regurgitation, 

354 
in aortic stenosis, 345 
in mitral regurgitation, 

326 
in mitral stenosis, 336 
in myocarditis, 376 
in pericarditis with ef- 
fusion, 380 
in pneumopericardium, 

391 
in tricuspid regurgita- 
tion, 372 



INDEX. 



465 



Apex beat, palpation of, 250 

influence of bony thorax 
on, 251 
of cardiac changes on, 

253 
of changes in lung tis- 
sue on, 252 
in pericardium. 253 
in pleura on, 252 
of posture on, 250 
of soft parts on, 251 
in pulmonary regurgita- 
tion, 367 
Appendicitis, 438 
Appendix, anatomy of, 41 
palpation of, 437 
vermiform, 41 
Arterial murmurs, 317 
pulsations, 245 
in anaemia, 246 
in aortic regurgitation, 246 
in chlorosis, 246 
conditions causing, 246 
cardiac, 246 
vascular, 246 
in Grave's disease, 246 
in rigid blood-vessels, 246 
Arterio-capillary fibrosis. See 

Arterio-sclerosis. 
Arterio-sclerosis, 402 
cardiac changes of, 403 
cardiac sounds in, 403 
murmurs in, 403 
physical signs of, 403 
stages of, 402 

superficial blood-vessels in, 
403 
Artery, pulmonary, 35 
Ascites, 415, 448 ' 
abdomen in, 416 
causes of, 416 

differential diagnosis of, 417 
fluctuation in, 416 
Asthma, 47, 197 
causes of, 197 
condition of lungs between 

attacks, 198 
condition of lungs during 

attacks, 197 
differential diagnosis of, 200 
physical signs of, 198 

30 



Atelactasis, 174 
Auscultatory percussion, 102 
Auscultation of abdomen, 452 
sounds heard in, 452 

of abdominal organs, 452 

of the circulatory system, 285 

of cough, 148 

of the heart, 285 

of lung, 105 

methods of, 105, 285 
technique of. 106, 

of thorax, 105 

use of stethoscope in, 285 
Axillary region, 20 

B 

Bacceli's sign, 233 
Barrel-shaped chest, 46 
Bell sound, 149 
tympany, 149 
Bladder, distended, 440 
Blood-vessels, impulse due to 
changes in, 245 
palpation of, 256 
pulsation of, in aortic regur- 
gitation, 354 
rigid. arterial pulsations in,246 
superficial, in arterio-scle- 
rosis, 403 
Brain, diseases of. irregular 

pulse due to, 269 
Breath sounds, alteration in 
duration of, 120 
in quality and pitch of, 

122 
in rhythm in, 119 
amphoric, characteristic of, 

144 
blowing, 123 

causes of prolonged expira- 
tory, 120 
cavernous, characteristic of, 

144 
changes in intensity of, 118 
character of, 108 
conditions modifying con- 
duction of, by columns 
of air, 134 
conduction of, by air, 108 
by tissue, 109* 



466 



INDEX. 



Breath sounds, difference be- 
tween inspiratory and 
expiratory, 114 
dry rales in, 138 
effects of changes in bron- 
chioles and alveoli on, 
111 
of consolidation on, 142 
of plugging of bronchus 
on, 139 
exaggerated or compensa- 
tory, 134 
high-pitched, 123 
influence of bronchi on, 137 
of changes in pleura on, 

150 
of increase in size of air 

spaces on, 143 
of increase of tissue in 
the walls of bronchi 
and alveoli on, 141 
of larynx on, 135 
of movement of tidal air 

on, 134 
of tension on, 140 
of thoracic walls on, 151 
intensity of, 108 
laryngeal, 107 
modification of, in different 
divisions of bronchi, 109 
through tissue conduc- 
tion, 110 
moist rales in, 139 
normal, elements of, 113 

physiology of, 106 
regional variations of, 115 
tracheal, 123 
tubular, 123 
types of, 118 
Broadbent's sign, 243 
Bronchi and trachea, anatomy 
of, 23 
influence of, on breath sound, 

137 
position of, 23 
Bronchial breathing in pericar- 
ditis, with effusion, 388 
pure, 123 
Bronchiectasis, 163 
causes of, 164 
differential diagnosis of, 166 



Bronchiectasis, differentiated 
from fetid bronchor- 
rhoea, 168 
from gangrene, 168 
from general bronchitis, 168 
from localized empyema 
opening into a bronchus, 
169 
from pulmonary abscesses, 

168 
from pulmonary tubercu- 
losis, 167 
physical signs of, 164 
Bronchitis, 152 
acute, 152 

differential diagnosis of, 158 
differentiated from acute 
diffuse pulmonary tu- 
berculosis, 159 
from broncho-pneumonia, 

159 
from chronic oedema, 160 
physical signs of, 153 
chronic, 160 

differential diagnosis of, 

163 
physical signs of, 162 
varieties of, 161 
classification of, 152 
of the larger tubes, 152 
of the middle sized tubes, 153 
of the smaller tubes, 153 
of the smallest tubes, 153 
Bronchophony, 147 
Broncho-pneumonia, 172 

differentiated from acute 

bronchitis, 159 

phthisis. See pulmonary 

tuberculosis, acute 

Broncho-vesicular breathing, 122 

Bronchus, left, branches of, 24 

plugging of, effect on breath 

sounds, 139 
right, branches of, 24 
Bruit in aneurism of aorta, 399 



CLecum, anatomy of, 41 
Cancer of intestines. 438 

of liver, 427 
of pancreas, 420 



INDEX. 



467 



Capillary pulse in aortic regur- 
gitation, 246 
Cardia, 38 
Cardiac dilatation, 374 

differentiated from adher- 
ent pericardium, 391 
irregular pulse due to, 269 
dropsy. See Cardiac (Edema 
dullness, areas of, influence of 
bony thorax on, 281 
of cardiac changes on, 

282 
of changes in pericar- 
dium on, 282 
of lung on, 280 
of pleura on, 280 
soft parts on, 280 
normal, conditions modi- 
fying, 279 
outline of, 275 
in mitral regurgitation, 
328 
in consolidation of lung, 

281 
in dilatation of heart, 282 

of left ventricle, 283 
dullness in emphysema, 280 
in hypertrophy of heart, 283 
in hypertrophy of ventricle, 

283 
in pericarditis, 282 
in pericarditis with effu- 
sion, 382 
in retraction of left lung, 

281 
in thickening of pleura, 281 
dyspnoea, characteristics of, 
248 
differentiated from asthma, 

200 
from emphysema, 197 
types of, 248 
flatness, area of. in aortic 
stenosis, 347 
influence of bony thorax 
on, 280 
areas of, influence of car- 
diac changes on, 282 
of lung on, 280 
of changes in pericar- 
dium on, 282 
of pleura on, 280 



Cardiac flatness, areas of influ- 
ence of soft parts on, 280 
in mitral regurgitation, 

328 
normal conditions modi- 
fying, 279 
outline of, 276 

method of determining. 
276 
in consolidation of lung, 

281 
in dilatation of heart, 282 

of left ventricle, 283 
in emphysema, 280 
in hypertrophy of heart, 282 

of left ventricle, 282 
in pericarditis, 282 

with effusion, 383 
in retraction of left lung,281 
in thickening of pleura, 281 
hypertrophy, 374 

differentiated from adher- 
ent pericardium, 391 
impulse in myocarditis, 376 
murmurs, 297 
(edema, differentiated from 

renal, 248 
sounds in aneurism of aorta, 
399 
in arteriosclerosis, 403 
changes in rhythm of, 
296 
in embryocardia, 296 
in cantor or gallop 
rhythm, 296 
in reduplication of 
sounds, 296 
intensity of, changes in. 
292 

diminution of. 295 
first sound, 295 
second sound. 295 
increase of, 293 
first sound, 293 
second sound, 294 
modifications of, 292 
in myocarditis, 377 
normal, characteristics of, 

286 
in pericarditis with effu- 
sion, 388 
in pneumo-pericardium, 392 



468 



INDEX. 



Cardiac weakness, irregularity 
of pulse in, 266 

Cardiopulmonary sounds, 321 

Cardio - respiratory murmurs, 
differentiated from mitral 
regurgitation, 333 

Catarrh, pulmonary, 172 

Catarrhal pneumonia, dissemi- 
nated, 172 

Cavernous breathing, 123 
resonance, 148 

Chest, 17 
alar, 48 
anatomy of, 17 
barrel- shaped, 46 
bilateral enlargement of, 47 
contents of thoracic region, 

21 

depressions or retractions 

of, 57 
emphysematous, 46 
local bulgings of, 56 
normal, description of, 44 

physiological departures 
from 46 
paralytic, 48 
pathological, 46 
phthisical, 49 
pigeon breasted, 52 
pterygoid, 48 
rachitic types of, 50 
regions of anterior surface 
of, 18 

lateral surface of, 20 

posterior surface of, 19 
unilateral diminution in size 
of, 54 

enlargements of, causes of, 

52 

Cheyne-Stokes breathing, 63 
Chlorosis, arterial pulsations 
in, 245 
venous pulsation in, 247 
Circulatory system, 237 
auscultation of, 285 
fluoroscopic examination of, 

461 
palpation of, 249 
percussion of, 274 
Circumscribed aneurism of 
aorta, 393 



Cirrhosis of lung, 185 

Cog-wheel breathing, 119 

Coin resonance, 149 

Congestion of lung, acute, 169 

Consumption. See Pulmonary 
Tuberculosis 

Corrigan's pulse. 356 

Cough, auscultation of, 148 

Crepitations, 126 
dry, 131 
moist, 131 

Cyanosis in obstruction of pul- 
monary artery, 364 

Cylindrical aneurism of aorta, 
"393 

Cysts of pancreas, 421 



Depressions, local, of chest, 

causes of, 57 
Diastolic murmurs, rhythm of, 

301 
Dilatation, cardiac, 374 

physical signs of, 375 
Drummond's sign in aneurism 

of aorta, 400 
Dry pericarditis, 378 
Duodenum, anatomy of, 41 
Dynamic murmurs, 298 
Dysphagia in aneurism of aorta, 

397 
Dyspnoea, expiratory, 154 
inspiratory, 154 



Ellis, curved line of, 227 
Emphysema, 189 

cardiac dullness in, 281 
flatness in, 281 
condition of lung in, 190 
differential diagnosis of, 196 
differentiated from cardiac 
dyspnoea, 197 
from hydro-pneumo thorax, 

197 " 
from pneumo-thorax, 196 

effects of, 190 
physical signs of, 192 



INDEX. 



469 



Emphysema, pulmonary, 47 

types of, 189 
varieties of, 189 

Emphysematous chest, 46 

Endocardial murmurs. See 
Murmurs, Cardiac 

Endocarditis, acute, differen- 
tiated from pericarditis, 389 

Exocardial murmurs, 317 



1-\ecal impaction. 439 
Fibrinous pericarditis, 378 
Fibroid phthisis, 185 
Flint murmur, differentiated 

from mitral stenosis, 343 
Florid phthisis. See Pulmo- 
nary Tuberculosis, Acute 
Fluoroscopic examinations, 455 
See also X-rav 
of adhesive pericarditis. 

462 
of aneurism, 462 
of circulatory system, 461 
of hypertrophy and dilata- 
tion of the heart, 462 
of mitral stenosis, 462 
of pericarditis with effu- 
sion, 461 
picture, conditions causing 
dark areas in, 459 
effect of calcareous de- 
posits on, 460 
changes in lung on. 459 
fibroid changes on. 459 
of normal thorax, 458 
pleural effusion in. 460 
Fremitus friction, 74 

splashing or succussion, 4 
vocal, causes of. 67 See also 
Vocal Fremiti* 
Friction, fremitus. 74 
in pericarditis, 356 
sounds, 131 
creaking, 131 
dry, 131 
grating, 131 
grazing, 131 
leathery, 131 
moist, 131 



Friction sounds in pericarditis 
386 
pleuro-pericardial, 321 
rasping, 131 
rubbing, 131 
Functional murmurs, 298 
Fusiform aneurism of aorta, 
393 



<;.\ll bladder, 39 

enlargements of, 429 
causes of, 429 
characteristics of, 429 
palpation of. 429 
tumors of. 429 

differential diagnosis of, 

430 

Galloping consumption. See 

Pulmonary Tuberculosis. Acute 

(Gaseous pulse. 270 

Gerhardt's change of sound in 

percussion, 93 
Grave's disease, arterial pulsa- 
tions in, 246 
Grocco's paravertebral triangle. 

229 
Gurgles. 130 



H 

H^mic murmurs. See Ameniic 

Murmurs, differentiated from 

aortic stenosis. 350 
Half-moon space, 442 
Harrison furrow. 52 
Harsh breathing. 122 
Heart, anatomy of. 32 

and bronchi, relations be- 
tween great vessels at base 
of. 135 

apex of, 32 

approximate outline of, 34 

auricles of. 32 

auscultation of, 285 

cavities of, 32 

dilatation of, differentiated 
from pericarditis with ef- 
fusion. 391 

diseases of. diagnosis of, 323 

effect of pleurisy on, 223 



470 



INDEX. 



Heart, horizontal relations of 
orifices at base of, 32 
hypertrophy of, differentiated 
from pericarditis with ef- 
fusion, 391 
influence of changes in, on 
apex beat, 243 
on percussion sound, 97 
orifices of, 34 
palpation of, 249 
percussion of, 274 
reginal anatomy of, 32 
relation of, to bony thorax, 30 
surface markings of, 33 
Hemorrhagic infarction differ- 
entiated from lobar pneu- 
monia, 184 
pericarditis, 379 
Hinted or indistinct bronchial 

breathing, 122 
Hodgkin's disease, liver in, 425 

spleen in, 433 
Hydatid cysts of liver, 427 

of pleura, 233 
Hydro-pneumothorax, 234 

differentiated from emphy- 
sema, 196 
physical signs of, 235 
Hydrothorax, 47, 234 

physical signs of, 234 
Hypertrophic cirrhosis, liver in, 

425 

Hypertrophy, cardiac, 374 
physical signs of, 375 
Hypochondrium, left, percus- 
sion of, 441 
right, percussion of, 444 
Hysterical breathing, differen- 
tiated from asthma, 202 



I 

Indeterminate breathing, 122 
Infarction of spleen, 402 
Infarclavicular fossae, 19 
Infrascapula region, 19 
Inspection of abdominal organs, 
405 
technique of, 405 
of the circulatory system, 
237 



Inspection of the heart, 237 
technique of, 237 

of lungs, 43 

of thorax, 43 
technique of, 43 
Interlobular emphysema, 190 
Interrupted breathing, 119 
Interstitial emphysema, 190 
Intestines, concer of, 438 

intussusception of, 438 

palpation of, 437 

tumors of, 438 

percussion over, 450 
Intussusception of intestines, 

438 



Jerky breathing, 119 

K 

Kidneys, anatomy of, 40 
enlargements of, 435 
movable, 434 
palpation of, 435 
regional anatomy of, 40 
relation of, to bony thorax, 31 
tumors of, 435 

differential diagnosis of, 436 
differentiated by percussion 
from those of spleen, 
450 
percussion over, 450 
wandering, 434 



Laryngeal breath sounds, 107 

stenosis, differentiated from 
asthma, 201 
Larynx, influence of, on breath 

sounds, 135 
Leukaemia, liver in, 425 

spleen in, 433 
Lines, 21 

imaginary vertical, 21 

Poupart, 41 
Litten's phenomenon, 62 
Liver, abscess of, 427 

anatomy of, 39 

cancer of, 427 



INDEX. 



471 



Liver, congestion of, 424 

degeneration of, 425 

displacement of, 423 
causes of, 423 

enlargements of, differential 
diagnosis of, 428 
irregular, 424 
percussion over, 450 
uniform, 424 

fatty, 425 

flatness of, conditions modify- 
ing, 445 

in Hodgkin's disease, 425 

hydatid cysts of, 427 

in hypertrophic cirrhosis. 425 

influence of, on percussion 
sound, 97 

in leukaemia, 425 

obstructive disease of, 428 

palpation of, 422 

facts to be noted on, 422 

percussion of, 445 

in pernicious anaemia, 425 

pulsation of, in tricuspid re- 
gurgitation, 372 

regional anatomy of, 39 

relation of, to bonv thorax, 
30 

syphilis of, 426 

tumors of. 424 
Lobular pneumonia. 172 
Lungs, acute congestion of, 109 
causes of, 169 
physical signs of. 170 

anatomy of, 27 

auscultation of, 105 

borders of, 27 

cirrhosis of, 185 

collapse of, differentiated 
from lobar pneumonia, 185 

consolidation of, cardiac dull- 
ness in, 281 
flatness in, 281 

effect of pleurisy on, 223 

fissures of, 28 

influence of changes in, on 
apex beat, 242 

inspection of, 43 

lobes of, 28 

malignant disease of, 220 
physical signs of, 221 



Lungs. Palpation of, 65 
passive congestion of, 170 
causes of, 170 
physical signs of, 171 
percussion of, 76 
outlines of, 98 
relation of, to bony thorax, 

30. 31 
syphilis of, 219 

M 

McBurney's point, 43S 
Malaria, spleen in, 433 
Mediastinal tumors, differen- 
tiated from aneurism of aorta, 

401 
Mediastinum. 30 

influence of changes in, on 
apex beat, 245 
-Meninges, disease of. irregular 

pulse due to, 269 
Metallic tinkle, 130, 235 
Mitral obstruction, differen- 
tiated from tricuspid ob- 
struction, 370 
orifice, regurgitation at. 323 
presystolic murmurs. 304 
regurgitation, accentuation of 
pulmonic second sound 
in, 330 
area of cardiac dullness in. 
328 
flatness in. 328 
diagnosis of pathological 

condition in, 331 
differential diagnosis of. 333 
differentiated from mitral 
stenosis, 342 
from tricuspid regurgita- 
tion, 373 
effects of, 324 
irregularity of pulse in. 266 
location of apex beat in. 326 
murmur of, 328 
physical signs of. 326 
pulse in, 327 
stages of, 324 
thrill in, 327 
stenosis, 334 
causes of, 334 



472 



INDEX. 



Mitral stenosis, differential di- 
agnosis of, 342 
effects of, 335 
fluoroscopic examination of, 

462 
irregular pulse due to, 269 
location of apex beat in, 336 
murmur of, 338 
physical signs of, 336 
pulse in, 337 
thrill in, 337 
systolic murmurs, 306 
Movable kidneys, 434 
Mucous clicks, 130 
Murmurs, aortic diastolic, 310 
causes of, 312 
in aortic regurgitation, 357 
Murmur of aortic stenosis, 347 
systolic, 309 
causes of, 309 
arterial, 317 

causes of, 318 
in arterio-sclerosis, 403 
cardiac, 297 

area of diffusion of, 303, 305 
causes of, 297 
characteristics of, 299 
classification of, 298 

inorganic or non-valvu- 
lar, 298 
organic or valvular, 298 
condition of vibrations to 
surface, 304, 306, 309, 
311, 314 
intensity of, 298 
changes in, 298 
point of maximum inten- 
sity of, 303, 304 
quality of, 299 
rhythm of, 301 
time of, method of deter- 
mining, 302 
diastolic, in aneurism of 

aorta, 398 
diasystolic, rhythm of, 301 
exocardial, 317 
mitral presystolic, 304 

causes of, 304 
of mitral regurgitation, 328 
stenosis, 337 
systolic, 306 
causes of, 309 



Murmur in myocarditis, 377 
in obstruction of pulmonary 

artery, 365 
presystolic, rhythm of, 301 
of pulmonary regurgitation, 

368 
in pulmonic area, 365 
diastolic, 316 

causes of, 317 
systolic, 315 
causes of, 316 
systolic, 318 

rhythm of, 301 
in tricuspid obstruction, 370 
presystolic, 312 
causes of, 312 
regurgitation, 371 
systolic, 313 
causes of, 315 
venous, 319 
causes of, 319 
Myocarditis, acute, 375 
forms of, 375 
physical signs of, 375 
chronic, 376 

apex beat in, 376 
cardiac impulse in, 376 
sounds in, 377 
forms of, 376 
murmur in, 377 
physical signs of, 376 
irregular pulse due to, 269 
Myocardium, disease of, 374 



N 

Nervous system, disturbances 
of, irregular pulse due 
to, 269 



Obstructive disease of liver, 

428 
(Edema, of lungs. See Pulmo- 
nary (Edema 
pulmonary, chronic, differen- 
tiated from acute bron- 
chitis, 160 
Omentum, palpation of, 417 



INDEX. 



473 



Omentum, tumors of, charac- 
teristic of, 417 
differential diagnosis of, 422 
( )rifices of heart, 34 
Ovaries, tumors of, 440 



Palpation of abdominal 
organs, 412 
method of, 412 
of aorta, 256 
of appendix, 437 
of blood-vessels, 256 
of the circulatory system. 249 
for fluctuation, 75 
friction fremitus in. 74 
of gall-bladder, 429 
of heart, 249 
of intestines, 437 
of kidneys, 434 
of liver, 422 
of lung, 65 
method of counting ribs in, 

66 
of omentum, 417 
for pain, 74 
of pancreas, 420 
of pelvic organs. 439 
of peritoneum, 414 
respiratoiy movements in. 66 
of rhonchi and palpable rales, 

74 
of splashing or succussion 

fremitus. 74 
of spleen. 431 
of stomach. 418 
technique of. 65, 249 
of thorax, 65 
value of, 65, 249 
vibratory phenomena in. 67 
Pancreas, anatomy of. 40 
cancer of, 420 

differential diagnosis of, 
421 
cysts of, 421 

differential diagnosis of, 
422 
palpation of, 420 
tumors of, 420 
Paralytic chest, 48 



Patent ductus anteriosus differ- 
entiated from aortic 
steno>i». 351 
from pulmonary ob- 
struction, 366 

Pectoriloquy, 147 

Pelvic organs, palpation of. 439 

tumors of. 439 

Percussion of abdomen, 441 
of abdominal organ>. 441 
auscultatory. 102 
of the circulating system, 274 
fluid in abdominal cavity in. 

448 
of the heart, 274 
of left hypochondrium. 441 
of liver. 445 
of lung. 76 
methods of. 79. 274 

immediate or direct. 79 
mediate or indirect. 79 
technique of. 80 
cutlines of lung, 98 
over abdominal tumors, 450 
over enlargements of liver. 
450 
of spleen, 450 
over faecal accumulations. 450 
ever tumors of intestines. 4.30 
of kidney, 450 
of pelvic organs. 450 
of stomach. 450 
of the proecordia. 274 

areas of. 274 
in pneumopericardium. 392 
of right hypochondrium. 444 
sound, conditions modifying, 
84 
cracked-pot sound in. 93 
duration of. 78 
elements of, 76 
Friedrich's respira tory 

change of sound, 93 
Gerhardt's change of sound 

in. 93 
individual and regional 

variations of. 97 
influence of the bony thor ax- 
on. 86 
of change in air spaces 
on, 92 



^74 



INDEX. 



Percussion sound, influence of 
change in amount of 
pulmonary tissue on, 91 
of tension on, 89 
of heart on, 97 
of liver on, 97 
of the pleura on, 87 
of pulmonary consolida- 
tion on, 96 
tissue on, 89 
' of the soft parts on, 84 
intensity of, 76 
modified by site of consoli- 
dation, 96 
pitch of, 77 
quality of, 76 
Wintrich's change of sound 

in, 93 
of splenic area, 443 
stethoscopic, 102 
of stomach, 447 
of thorax, 76 
of true abdomen, 447 
Pericardial friction sound dif- 
ferentiated from mitral re- 
gurgitation, 333 
from mitral stenosis, 343 
sac, 31 
Pericarditis, 378 

adhesive, fluoroscopic exami- 
nation of, 462 
cardiac dullness in, 281 

flatness in, 281 
differential diagnosis of, 389 
dry, 378 

friction fremitus in, 382 
sound in, 386 
fibrinous, 378 

friction fremitus in, 382 
sound in, 386 
forms of, 378 
hemorrhagic, 379 
physical signs of, 380 
plastic, 379 

friction fremitus in, 382, 
384 
sound in, 386 
purulent, 379 
sero-fibrinous, 379 
with adhesions, 379 
with effusion, 379 

segophony in, 388 



Pericarditis with effusion, 
bronchial breathing in, 

388 
cardiac dullness in, 384 
flatness in, 384 
impulse in, 382 
sounds in, 388 
differential diagnosis of. 

390 
fluoroscopic examination 

of, 461 
location of apex beat in, 

380 
pulmonary resonance in, 

385 

respiratory sounds in, 3S8 

Skoda's resonance in, 385 

Pericardium, anatomy of, 31 

diseases of, diagnosis of, 378 

influence of changes in, on 

apex beat, 243 
regional anatomy of, 31 
sounds made in, 320 
characteristics of, 320 
diagnostic features of. 321 
Peritoneum, palpation of, 414 
Peritonitis, general, abdominal 

walls in, 415 
Perityphlitic abscess, 438 
Phthisical chest, 49 

causes of deformity, 50 
Phthisis. See Pulmonary Tuber- 
culosis 
acute. See Pulmonary Tuber- 
culosis, Acute 
catarrhal. See Pulmonary 
Tuberculosis, Acute 
fibroid, 185 

pneumonic. See Pulmo- 
nary Tuberculosis, Acute 
tubercular pneumonic. See 
Pulmonary Tuberculosis, 
Acute. 
Pigeon-breasted chest, 52 
Plastic pericarditis, 379 
Pleura, anatomy of, 29 
hydatid of, 233 
influence of change in on 
apex beat, 252 
on breath sounds, 150 
of diseases of, on apex beat, 
241 



INDEX. 



475 



Pleura, influence of diseases of, 
on percussion sounds, 87 
left, effusions into, differ- 
entiated from pericarditis 
with effusion, 391 
relation of, to bony thorax, 

30, 31 
surface markings of, 30 
thickening of, cardiac dull- 
ness in, 281 
flatness in, 281 
Pleurisy, 222 

differential diagnosis of, 233 
physical signs of, 225 
effect of, on heart, 223 

on lung, 223 
forms of, 221 
with adhesion, 224 

physical signs of, 226 
with effusion, 47 
condition of sac in, 223 
differentiated from lobar 

pneumonia. 183 
physical signs of, 225 
Pleuritic friction differentiated 
from pericarditis, 389 
sounds, differentiated from 
mitral regurgitation, 333 
Pleurodynia, 233 
Pleuro-pericardial friction, dif- 
ferentiated from pericar- 
ditis, 389 
friction sounds, 321 
Pneumonia, chronic interstitial, 
185 
causes of, 186 
condition of lungs in, 185 
differential diagnosis of, 

189 
physical signs of, 187 
types of, 186 
differentiated from pleurisy, 

233 
lobar, 175 

condition of lungs in, 175 
differential diagnosis of. 183 
differentiated from acute 
pulmonary congestion, 
183 
from collapse of lung, 
185 



Pneumonia lobar, differenti- 
ated from hemorrhagic 
infarction, 184 
from pleurisy with effu- 
sion, 183 
physical signs of, 177 
stages of, 175 

e ngo rgemen t , 175 
gray hepatization or 

resolution. 17<> 
red hepatization or 
consolidation. 175 
terminations of. 176 
lobular, 172 
causes of, 173 
condition of lung in. 171 
confluent, 173 
differential diagnosis of, 

174 
differentiated from acute 
disseminated tuberculo- 
sis, 174 
from lobar pneumonia. 175 
from pulmonary collapse, 

174 
disseminated, 173 
physical signs of. 173 
yarieties of. 172 
Pneumo-pericardium. 391 
apex beat in. 391 
cardiac sounds in. 392 
percussion in, 392 
physical signs of, 391 
water-wheel sounds in. 392 
Pneumothorax. 234 

differentiated from emphy- 
sema. 196 
physical signs of. 234 
Pmecordia, inspection of, 239 
bulging of, causes of, 239 
percussion of, 274 
Pre-systolic murmurs, rhythm 

of/301 
Pterygoid chest. 48 
Puerile breathing, 141 
Pulmonary artery. 35 
obstruction of. 362 
causes of. 362 
cyanosis in, 364 
differential diagnosis of. 

366 
effects of, 363 



476 



INDEX. 



Pulmonary artery, obstruction 
of, murmurs in, 364 
physical signs in, 364 
thrill in, 365 
catarrh, 172 
congestion differentiated from 

lobar pneumonia, 183 
emphysema, 47 
obstruction d i ff e r e n tiated 

from aortic stenosis, 350 
oedema, 171 
causes of, 171 
physical signs of, 172 
regurgitation, 367 
apex beat in, 367 
causes of, 367 
differential diagnosis of, 368 
regurgitation, effects of, 367 
murmur of, 367 
physical signs of, 367 
resonance in pericarditis, 385 
tissue, influence of, on percus- 
sion sounds, 89 
tuberculosis, acute, 204 

differential diagnosis of, 

206 
physical signs of, 205 
types of, 204 
causes of, 202 
chronic, 208 

condition of lung in, 208 
physical signs of, 211 
stages of, 211 
effect of, on lung, 203 
forms of, 203 
secondary changes of, 203 
site and progress of, 209 
valve, 33 
Pulmonic diastolic murmurs, 316 
obstruction d i ff e r e n tiated 
from tricuspid regurgita- 
tion, 373 
sound, accentuation of, 295 
systolic murmurs, 315 

Pulse, 257 

in aneurism of aorta, 397 
in aortic regurgitation, 355 

stenosis, 346 
in conditions of, modifying 
elasticity of arter- 
ies, 269 



Pulse, in condition of, resist- 
ance in arteries and capil- 
laries, 269 
dicrotism of, 270 
elements of, 259 
examination of, 258 
force of, 265 

diminution of, causes of, 265 
increase, in, causes of, 265 
irregularity in, 266 
frequency of, 260 
intermittent, causes of, 267 

characteristics of, 266 
irregular, causes of, 268 
characteristics of, 267 
due to reflex irritation, 268 
in mitral regurgitation, 327 
Pulse in mitral stenosis, 337 
normal, 259 
rapid, causes of, 261 
slow, causes of, 264 
tension of, high, causes of, 
272 
low, causes of, 270 
in tricuspid obstruction, 369 
Pupil, contraction of, in aneur- 
ism of aorta, 395 
Purulent pericarditis, 379 
Pylorus, 39 



Rachitic chest, causes of, 52 

rosary, 52 
Radiograph in cardiac diseases, 

462 
Rales, crepitant, 126 

diagnostic significance of, 

127 
mode of production of, 127 
dry, 138 

cause of, 123 
differentiation of pleural 
from bronchial, 132 
of small moist from crepi- 
tant, 129 
friction, 131 

dry, 131 
moist, 131 
indeterminate or indefinite. 

132 
moist, 139 



INDEX. 



477 



Rales, moist, characteristics of, 
126 
classification of. 128 
importance of size of, 128 
large, 125 
medium, 125 
quality of sound of. 120 
small, 125 
sibilant, 125 
sonorous. 124 
stridor. 124 
Regional anatomy, 17 
Regions of abdomen. 30 
of anterior surface of chest. 

18 
of lateral surface of chest, 19 
of posterior surface of chest, 
18 
Regurgitation at aortic orifice, 
351 
at mitral orifice. 323 
causes of. 323 
at pulmonic orifice. 367 
Respiratory movements, 58 
abnormal, alteration in fre- 
quency in. 62 
diminished, causes of. 61 
increased, causes of, 60 
costal breathing in, 

causes of. 59 
inferior costal diaphrag- 
matic breathing in, 
causes of. 60 
inferior costal in adult 

male. 59 
normal. 59 

alteration in frequency 
in, 62 
in rhythm in, 63 
costal in women, 59 
diaphragmatic abdomi- 
nal in children. 59 
murmurs. See Breath Sounds 
rhythm of. in adult. 63 
in aged, 63 
alteration in, 63 
sounds in pericarditis with 
effusion. 388 
types of, 118 
system, 37 
Rhonchi and palpable rales, 
palpation of. 74 



Rotch's sign, 385 
Rude respiration, 122 



Sacciform aneurism of aorta. 

393 
Sanson's signs in aneurism of 

aorta, 400 
Serofibrinous pericarditis. 379 
Skoda's resonance, 227, 385 
Splashing fremitus, 74 
Spleen, abscess of, 433 
anatomy of, 40 
enlargement of, 431 
causes of, 432 
percussion oyer, 432 
in Hodgkin's disease, 433 
infarction of, 433 
in leukaemia. 433 
in malaria. 433 
palpation of. 431 
percussion of, 443 
regional anatomy of. 40 
relation of, to bony thorax. 31 
syphilis of, 433 
tumors of. characteristics of, 
432 
differential diagnosis of, 
433 
Stenosis at mitral orifice, 334 
Stethoscope, use of, in auscul- 
tation, 285 
Stethoscopic percussion, 102 
Stomach, anatomy of, 38 
dilated. 418 
displaced, 418 
palpation of. 418 
percussion of, 447 
regional anatomy of, 38 
shape of. 38 
surface markings of, 39 
tenderness oyer, 418 
tumors of, 419 

characteristic features of. 

420 
percussion oyer, 450 
Sub-diaphragmatic abscess, dif- 
ferentiated from pleurisy, 
234 
Subtubular breathing, 122 
Succussion fremitus, 74 



478 



INDEX. 



Succussion fremitus, sound, 131 
Supraclavicular fossae, 19 
Syphilis of liver, 426 
of lung, 219 

differential diagnosis of, 

220 
varieties of, 219 
of spleen, 433 
Systolic murmurs, rhythm of, 
'301 



Table of contents of abdominal 
regions, 38 
of thoracic regions, 21 
Thoracic aorta, aneurism of, 245 
regions, 21 

walls, influence of on breath 
sound, 151 
Thorax, anatomy of, 18 
antero-posterior relation of 
important structures in, 29 
auscultation of, 105 
bony, influence of, on percus- 
sion sounds, 86 
contents of, 21 
inspection of, 43 
palpation of, 65 
percussion of, 76 
surface markings of, 19 
Thrill in aneurism of aorta, 396 
in aortic stenosis, 346 
in mitral regurgitation, 327 

stenosis, 337 
in obstruction of pulmonary 

artery, 364 
in tricuspid obstruction, 369 
Thrills, 255 
causes of, 255 
character of, 255 
Topographical and relational 

anatomy, 17 
Trachea and bronchi, anatomy 
of, 23 
position of, 23 

relation of, to anterior 
chest wall, 23 
to posterior chest wall, 24 
Tracheal stenosis, differentiated 
from asthma, 201 



Tracheal tugging, 37, 256 

in aneurism of aorta, 397 
method of examining for, 
256 
Transition breathing, 122 
Tricuspid obstruction, 369 

differential diagnosis of, 370 
effects of, 369 
murmur in, 370 
physical signs of, 369 
pulse in, 369 
thrill in, 370 
veins in, 369 
pre-systolic murmurs, 312 
regurgitation, 370 
causes of, 370 
differential diagnosis of, 373 
differentiated from mitral 

stenosis, 342 
effect of, 371 
location of apex beat in, 

372 
murmurs in, 373 
physical signs of, 372 
pulsation of liver in, 373 
stenosis differentiated from 

mitral stenosis, 343 
svstolic murmurs, 313 
valve, 33 
Tubucular pneumatic phthisis. 
See Pulmonary Tuberculosis, 
Acute. 
Tuberculosis, acute diffuse pul- 
monary, differentiated from 
acute bronchitis, 159 
pulmonary, d i ff e r e n tiated 
from bronchiectasis, 166 
Tumors of abdominal walls, 
palpation of, 413 
of kidneys, palpation of, 434 
of liver, palpation of, 424 
mediastinal, d i ff e r entiated 
from aneurism of aorta, 401 
of omentum, palpation of, 417 
of ovaries, 440 
of spleen, differential diag- 
nosis of, 432 
palpation of, 432 
of stomach, palpation of, 419 
of uters, 439 
Typhlitis, 438 



INDEX. 



479 



U 

Ulcerative tuberculosis, 
chronic. See Pulmonary Tu- 
berculosis, Chronic 
Unilateral diminution in size of 
chest, 54 
enlargements of chest, causes 
of, 52 
Uterus, tumors of, 440 



Valve areas, 290 

aortic. 291 
mitral, 290 
pulmonic, 292 
tricuspid, 291 
Valvular, disease, chronic, dif- 
ferentiated from pericar- 
ditis. 389 
N'eiled puff, 149 

Veins, superficial, in aneurism 
of aorta. 395 
in tricuspid obstruction, 369 
Venous murmurs. 319 
pulsation, 247 
abnormal. 247 
in anaemia, 247 
in chlorosis, 247 
normal, 247 
Ventricle, left, 33 

right, 32 
Vermiform appendix, 41 
Vocal fremitus, causes of, 67 
in child, 68 

diminished, by changes in 
bronchi. 72 
in the chest wall, 73 
in pleura. 73 



Vocal fremitus, diminished, by 

changes in pulmonary 

tissue, 72 
increase of, cause of. 7 1 

in children, 72 

by pulmonary consolida- 
tions, 71 

by tension of pulmonary 
tissue. 72 

over cavities, 72 
in man. 68 

modified by chesl wall. 70 
normal variation in. 68 
over the apices, 69 
physiological increase of on 

right side, 69 
regional variations in, 68 

causes of, 68 
technique of. 68, 7<> 
in woman. 68 
resonance, characteristic- of, 

145 
conditions modifying. 145 
whispered voice or whis- 
pered resonance, 145 

W 

Wandering kidneys. 434 
Water-hammer pulse. 356 
Water-wheel sound in pneumo- 
pericardium, 392 
Wavy breathing, 119 
YVintrieh's change of sound in 
percussion, 93 



X Ray examinations. 4.V> 
apparatus for. 455 
value of. 457 



t 



